1.3.6.1.4.1.19376.1.3.1.6/static-2008-08-08T000000

From pubswiki
Revision as of 12:56, 9 August 2018 by Adbot (talk | contribs) (Automated ADBot page content)
Jump to navigation Jump to search
Id1.3.6.1.4.1.19376.1.3.1.6
ref
XDLAB-
Effective Date2008‑08‑08
Other versions this id:
    StatusKgreen.png ActiveVersion Label2017
    NameLaboratoryObservationDisplay NameLaboratory Observation
    Description
    The document SHALL contain at least one Laboratory Observation (See REFERENCE) under the Specimen Act of each Laboratory Data Processing Entry (See REFERENCE). The Laboratory Observation SHALL record a single laboratory observation in the document, either standalone or as part of a battery. It should be distinguished from the PCC Simple Observation template.
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.1.6
    ClassificationCDA Entry Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Uses
    Uses 6 templates
    Uses as NameVersion
    1.3.6.1.4.1.19376.1.3.3.1.2.1ContainmentKgreen.png Non-Human Subject (2017)DYNAMIC
    1.3.6.1.4.1.19376.1.3.3.1.3.1ContainmentKgreen.png Human Patient with Non-Human Subject (2017)DYNAMIC
    1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)DYNAMIC
    1.3.6.1.4.1.19376.1.3.10.9.17ContainmentKgreen.png Author with Name, Addr, Telecom (2017)DYNAMIC
    1.3.6.1.4.1.19376.1.5.3.1.4.2ContainmentKgreen.png IHE Comment Entry (2014)DYNAMIC
    1.3.6.1.4.1.19376.1.3.1.2ContainmentKgreen.png Specimen Collection (2017)DYNAMIC
    RelationshipGeneralization: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
    Example
    Example
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.3.1.6"/>  <id root=" " extension=" "/>  <code code="10912-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Lead Measurement, Quantitative">
        <originalText>
          <reference value="pbTest"/>    </originalText>      </code>      <statusCode code="completed"/>  <effectiveTime value="20071108000000.0000-0500"/>  <value xsi:type="PQ" unit="mg/dL" value="6.4"/>  <interpretationCode code="H" codeSystem="2.16.840.1.113883.5.83"/>  <methodCode code=" " codeSystem=" " codeSystemName=" "/>  <specimen typeCode="SPC">
        <specimenRole classCode="SPEC">
          <id extension="555847399003" root="1.3.6.1.4.1.19376.1.3.4"/>      <specimenPlayingEntity>
            <code code="BLD" codeSystem="2.16.840.1.113883.5.129" codeSystemName="HL7" displayName="Blood"/>      </specimenPlayingEntity>        </specimenRole>      </specimen>      <performer typeCode="PRF">
        <templateId root="1.3.6.1.4.1.19376.1.3.3.1.7"/>    <!-- ... -->
      </performer>      <author typeCode="AUT">
        <!-- ... -->
      </author>      <participant typeCode="AUTHEN">
        <templateId root="1.3.6.1.4.1.19376.1.3.3.1.5"/>    <!-- ... -->
      </participant>      <participant typeCode="RESP">
        <!-- ... -->
      </participant>      <participant typeCode="DEV">
        <!-- ... -->
      </participant>      <entryRelationship typeCode="COMP">
        <act classCode="ACT" moodCode="EVN">
          <templateId root="2.16.840.1.113883.10.20.1.40"/>      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.2"/>      <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation Comment"/>      <text>
            <reference value="pbTestComment"/>      </text>          <statusCode code="completed"/>    </act>      </entryRelationship>      <entryRelationship typeCode="REFR">
        <sequenceNumber value="1"/>    <observation classCode="OBS" moodCode="EVN">
          <templateId root="1.3.6.1.4.1.19376.1.3.1.6"/>      <code code="10912-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Lead Measurement, Quantitative">
            <originalText>
              <reference value="pbTest"/>        </originalText>          </code>          <statusCode code="completed"/>      <effectiveTime value="20071101000000.0000-0500"/>      <value xsi:type="PQ" unit="mg/dL" value="8.7"/>      <interpretationCode code="H" codeSystem="2.16.840.1.113883.5.83"/>      <entryRelationship typeCode="COMP">
            <act classCode="ACT" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.1.40"/>          <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.2"/>          <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation Comment"/>          <text>
                <reference value="pbTestComment"/>          </text>              <statusCode code="completed"/>        </act>          </entryRelationship>        </observation>      </entryRelationship>      <referenceRange typeCode="REFV">
        <observationRange classCode="OBS" moodCode="EVN.CRT">
          <value xsi:type="IVL_PQ">
            <low value="0.0" unit="mg/dL"/>        <high value="5.0" unit="mg/dL"/>      </value>          <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>    </observationRange>        <lab:precondition typeCode="PRCN">
          <lab:criterion classCode="COND">
            <lab:code code="AGE"/>        <lab:value xsi:type="IVL_PQ">
              <lab:low value="35" unit="Y"/>          <lab:high value="55" unit="Y"/>        </lab:value>          </lab:criterion>        </lab:precondition>      </referenceRange>    </observation>
    Example
    Example
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.3.1.3"/>  <code code="11273-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="ERYTHROCYTES"/>  <statusCode code="completed"/>  <effectiveTime value="20060321063000.0000-0500"/>  <value xsi:type="PQ" value="4.95" unit="10*6/mm3"/>  <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>  <entryRelationship typeCode="REFR">
        <!-- Previous result 4.85 from Mar 12, 2006 08:15 -->
        <observation classCode="OBS" moodCode="EVN">
          <code code="11273-0" codeSystem="2.16.840.1.113883.6.1"/>      <statusCode code="completed"/>      <effectiveTime value="20060312081500.0000-0500"/>      <value xsi:type="PQ" value="4.85" unit="10*6/mm3"/>    </observation>      </entryRelationship>      <!-- reference range given patient sex -->
      <referenceRange typeCode="REFV">
        <observationRange classCode="OBS" moodCode="EVN.CRT">
          <value xsi:type="IVL_PQ">
            <low value="4.50" unit="10*6/mm3"/>        <high value="6.00" unit="10*6/mm3"/>      </value>        </observationRange>        <lab:precondition typeCode="PRCN">
          <lab:criterion classCode="COND">
            <lab:code code="SEX"/>        <lab:value xsi:type="CD" code="M" codeSystem="2.16.840.1.113883.5.1"/>      </lab:criterion>        </lab:precondition>      </referenceRange>    </observation>
    ItemDTCardConfDescriptionLabel
    hl7:observation
    		1 … 1M(Lab...ion)
    Treetree.png@classCode
    		cs1 … 1FOBS
    Treetree.png@moodCode
    		cs1 … 1FEVN
    Treetree.pnghl7:templateId
    		II1 … 1M(Lab...ion)
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.3.1.6
    Treetree.pnghl7:id
    		II0 … 1A Laboratory Observation identifier MAY be present.(Lab...ion)
    Treetree.pnghl7:code
    		CD1 … 1RUnique test code in an international standard (LOINC or SNOMED CT) or a national standard (e.g. JC10 in Japan)(Lab...ion)
    Treetree.pnghl7:statusCode
    		CS1 … 1M‘completed’ when the result is present.
    ‘aborted’ if the test could not be performed.    		(Lab...ion)
     CONF
    @code shall be "completed"
    or
    @code shall be "aborted"
    Treetree.pnghl7:effectiveTime
    		IVL_TS0 … 1RPhysiologically relevant time(Lab...ion)
    Treetree.pnghl7:value
    		ANY0 … 1RThe result obtained for this test using the appropriate data type. Numeric results use data type PQ, which includes the unit. The result is absent in case of ‘obsolete’ or ‘aborted’ observation.(Lab...ion)
    Treetree.pnghl7:interpretationCode
    		CE0 … 1ROne or more codes interpreting the result, expressed with ObservationInterpretation vocabulary (e.g. H = high, L = low)
    In case of a antimicrobial susceptibility test in microbiology, the vocabulary domain is ObservationInterpretationSusceptibility: S = susceptible, R = resistant, I = intermediate, VS = very susceptible, MS = moderately susceptible    		(Lab...ion)
    Treetree.pnghl7:methodCode
    		CE0 … 1Rmethod used for this observation expressed with ObservationMethod vocabulary (CWE)(Lab...ion)
    Choice0 … 1Elements to choose from:
    • hl7:subject containing template 1.3.6.1.4.1.19376.1.3.3.1.2.1 Non-Human Subject (DYNAMIC)
    • hl7:subject containing template 1.3.6.1.4.1.19376.1.3.3.1.3.1 Human Patient with Non-Human Subject (DYNAMIC)
    Treeblank.pngTreetree.pnghl7:subject
    		0 … 1subject in case of a non-human subject
    Contains 1.3.6.1.4.1.19376.1.3.3.1.2.1 Non-Human Subject (DYNAMIC)    		(Lab...ion)
    Treeblank.pngTreeblank.png where [hl7:relatedSubject]
    Treeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs0 … 1FSBJ
    Treeblank.pngTreetree.pnghl7:subject
    		0 … 1subject in case of a non-human subject
    Contains 1.3.6.1.4.1.19376.1.3.3.1.3.1 Human Patient with Non-Human Subject (DYNAMIC)    		(Lab...ion)
    Treeblank.pngTreeblank.png where [hl7:relatedSubject]
    Treeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs0 … 1FSBJ
    Treetree.pnghl7:performer
    		0 … *performer participation. Performer to supersede those recorded at higher level.
    Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC)    		(Lab...ion)
    Treeblank.png where [hl7:assignedEntity]
    Treeblank.pngTreetree.png@typeCode
    		cs0 … 1FPRF
    Treetree.pnghl7:author
    		0 … *Rauthor participation used to supersede the authors of higher level.
    Contains 1.3.6.1.4.1.19376.1.3.10.9.17 Author with Name, Addr, Telecom (DYNAMIC)    		(Lab...ion)
    Treeblank.png where [hl7:assignedAuthor]
    Treeblank.pngTreetree.png@typeCode
    		cs0 … 1FAUT
    Treetree.pnghl7:participant
    		0 … 1Other participants "AUTHEN", "RESP", and "DEV".
    • AUTHEN: The verifier of the battery organizer. In the case where a laboratory report has multiple verifiers. Each verifier is attached to the subset of batteries/observations he or she verified, by the means of a <participant> element.
    		(Lab...ion)
    Treeblank.png where [@typeCode='AUTHEN']
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FAUTHEN
    Treetree.pnghl7:participant
    		0 … 1Other participants "AUTHEN", "RESP", and "DEV".
    • RESP: The person responsible for the provision of the battery. In the case where this battery is subcontracted to an external laboratory, this external laboratory (with its address and telcom) and the actual performer is represented by a <performer> element, whereas the Director of this subcontractor laboratory is carried by the <participant> element being attached to the same level as the <performer> element.
    		(Lab...ion)
    Treeblank.png where [@typeCode='RESP']
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FRESP
    Treetree.pnghl7:participant
    		0 … 1Other participants "AUTHEN", "RESP", and "DEV".
    • DEV: A device or equipment, which was used to produce this battery of results (e.g. an analyzer).
    		(Lab...ion)
    Treeblank.png where [@typeCode='DEV']
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FDEV
    Treetree.pnghl7:entryRelationship
    		0 … *RComment on this Observation
    Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (DYNAMIC)    		(Lab...ion)
    Treeblank.png where [hl7:act [hl7:code [(@code = '48767-8' and @codeSystem = '2.16.840.1.113883.6.1')]]]
    Treetree.pnghl7:entryRelationship
    		0 … *RSpecimen Collection
    Contains 1.3.6.1.4.1.19376.1.3.1.2 Specimen Collection (DYNAMIC)    		(Lab...ion)
    Treeblank.png where [hl7:procedure]
    Treetree.pnghl7:entryRelationship
    		0 … *RPrevious observations obtained for the same patient, test, same method, same unit (1)(Lab...ion)
    Treeblank.png where [@typeCode='REFR']
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FREFR
    Treeblank.pngTreetree.pnghl7:observation
    		1 … 1R(Lab...ion)
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs1 … 1FOBS
    Treeblank.pngTreeblank.pngTreetree.png@moodCode
    		cs1 … 1FEVN
    Treeblank.pngTreeblank.pngTreetree.pnghl7:code
    		1 … 1R(Lab...ion)
    Treeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
    		1 … 1R(Lab...ion)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
    		1 … 1Fcompleted
    Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    		1 … 1R(Lab...ion)
    Treeblank.pngTreeblank.pngTreetree.pnghl7:value
    		1 … 1R(Lab...ion)
    Treetree.pnghl7:referenceRange
    		0 … 1RReference range for the current test result(Lab...ion)
    Treeblank.pngTreetree.png@typeCode
    		cs0 … 1FREFV
    Treeblank.pngTreetree.pnghl7:observationRange
    		1 … 1M(Lab...ion)
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FOBS
    Treeblank.pngTreeblank.pngTreetree.png@moodCode
    		cs0 … 1FEVN.CRT
    Treeblank.pngTreeblank.pngTreetree.pnghl7:value
    		0 … 1
    NL-NL.png interval (IVL) representation
    		(Lab...ion)
    Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretationCode
    		CE1 … 1R(Lab...ion)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
    		CONF0 … 1FN
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		0 … 1F2.16.840.1.113883.5.83 (Observation Interpretation)
    Treeblank.pngTreeblank.pngTreetree.pnglab:precondition
    		0 … *Extension to CDA Clinical statement(Lab...ion)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs1 … 1FPRCN
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnglab:criterion
    		1 … 1R(Lab...ion)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		cs1 … 1FCOND
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@moodCode
    		cs1 … 1FEVN
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnglab:code
    		CE1 … 1RCode of the criterion (e.g. age, sex)(Lab...ion)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnglab:value
    		1 … 1R
    NL-NL.png Value of the criterion
    		(Lab...ion)
    Retrieved from "http://pubswiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.3.1.6/static-2008-08-08T000000&oldid=1963"