| Template |
2.16.840.1.113883.10.20.22.4.2.2 - ccda2-ResultObservation |
| Id |
2.16.840.1.113883.10.20.22.4.2.2 |
| Classificatie |
CDA entry level template |
| Context |
Parent nodes van template element met id 2.16.840.1.113883.10.20.22.4.2.2 |
| Versie |
geldig vanaf 2013‑01‑31 status Onder revisie vóór de publicatie |
| Open/gesloten |
Open (ook andere dan gedefinieerde elementen zijn toegestaan) |
| Omschrijving |
 This template represents the results of a lab, radiology, or other study performed
on a patient.
The result observation includes a statusCode to allow recording the status of an
observation. “Pending” results (e.g., a test has been run but results have not been
reported yet) should be represented as “active” ActStatus. |
| Gebruikt door / Gebruikt |
| Gebruikt door / Gebruikt 1 template |
|
|
|
| Voorbeeld |
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.2.2"/>
<id root="7c0704bb-9c40-41b5-9c7d-26b2d59e234f"/>
<code code="4544-3" displayName="Hematocrit" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<statusCode code="completed"/>
<effectiveTime value="200803190830-0800"/>
<value xsi:type="PQ" value="35.3" unit="%"/>
<interpretationCode code="L" codeSystem="2.16.840.1.113883.5.83"/>
<author>
<time value="200803190830-0800"/>
<assignedAuthor>
<id extension="333444444" root="1.1.1.1.1.1.1.4"/>
<addr>
<streetAddressLine>1017 Health Drive</streetAddressLine>
<city>Portland</city>
<state>OR</state>
<postalCode>99123</postalCode>
<country>US</country> </addr>
<telecom use="WP" value="tel:+1(555)555-1017"/>
<assignedPerson>
<name>
<given>William</given>
<given qualifier="CL">Bill</given>
<family>Beaker</family> </name> </assignedPerson>
<representedOrganization>
<name>Good Health Laboratory</name> </representedOrganization> </assignedAuthor> </author>
<referenceRange>
<observationRange>
<value xsi:type="IVL_PQ">
<low value="34.9" unit="%"/>
<high value="44.5" unit="%"/>
</value> </observationRange> </referenceRange> </observation> |
| Voorbeeld |
Pending Result Observation Example
<observation classCode="OBS" moodCode="EVN">
<!-- ** Result observation ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.2.2"/>
<id root="aed821af-3330-4138-97f0-e84dfe5f3c35"/>
<code code="3094-0" displayName="Urea nitrogen, Serum" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<statusCode code="active"/>
<effectiveTime value="200803200930-0800"/>
<value xsi:type="PQ" nullFlavor="NI"/>
</observation> |
| Voorbeeld |
Original Lab Units in translation Example
<observation classCode="OBS" moodCode="EVN">
<!-- ** Result observation ** -->
<templateId root="2.16.840.1.113883.10.20.22.4.2.2"/>
<id root="a69b3d60-2ffd-4440-958b-72b3335ff35f"/>
<code code="6690-2" displayName="Leukocytes" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<statusCode code="completed"/>
<effectiveTime value="200803190830-0800"/>
<value xsi:type="PQ" value="6.7" unit="10*9/L">
<translation>
<originalText>6.7 billion per liter</originalText> </translation> </value>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
<author typeCode="AUT">
<time value="200803190830-0800"/>
<assignedAuthor>
<id extension="333444444" root="1.1.1.1.1.1.1.4"/>
</assignedAuthor> </author>
<referenceRange>
<observationRange>
<value xsi:type="IVL_PQ">
<low value="4.3" unit="10*9/L"/>
<high value="10.8" unit="10*9/L"/>
</value> </observationRange> </referenceRange> </observation> |
| Item |
DT |
Card |
Conf |
Omschrijving |
Label |
|
|
|
|
|
|
(ccda2-ResultObservation) |
 |
@classCode
|
|
|
1 .. 1 |
F |
OBS |
|
@moodCode
|
|
|
1 .. 1 |
F |
EVN |
|
hl7:templateId
|
|
|
1 .. 1 |
M |
|
conf‑7136 |
 |
|
@root
|
|
|
1 .. 1 |
F |
2.16.840.1.113883.10.20.22.4.2.2 |
|
hl7:id
|
|
|
1 .. * |
M |
|
conf‑7137 |
|
hl7:code
|
|
|
1 .. 1 |
M |
|
conf‑7133 |
|
Constraint |
SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem:
2.16.840.1.113883.6.96) (CONF:19211) |
|
Constraint |
Laboratory results SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or other
terminology named by the US Department of Health and Human Services Office of National
Coordinator or other federal agency (CONF:19212) |
|
hl7:text
|
|
|
0 .. 1 |
R |
|
conf‑7138 |
|
|
hl7:reference
|
|
|
0 .. 1 |
R |
|
conf‑15924 |
|
|
|
0 .. 1 |
|
|
|
hl7:statusCode
|
|
|
1 .. 1 |
M |
|
conf‑7134 |
|
CONF |
|
|
hl7:effectiveTime
|
|
|
1 .. 1 |
M |
|
conf‑7140 |
|
hl7:value
|
|
|
1 .. 1 |
M |
|
conf‑7143 |
|
hl7:interpretationCode
|
|
|
0 .. * |
R |
|
conf‑7147 |
|
hl7:methodCode
|
|
CE |
0 .. 1 |
|
|
conf‑7148 |
|
hl7:targetSiteCode
|
|
CD |
0 .. 1 |
|
|
conf‑7153 |
| Ingevoegd van 2.16.840.1.113883.10.20.22.4.119 CCDA2 Author Participation (DYNAMISCH) 0 .. *
|
|
hl7:author
|
|
|
0 .. * |
|
|
conf‑7149 |
|
|
hl7:templateId
|
|
|
1 .. 1 |
M |
|
conf‑32017 |
|
|
|
1 .. 1 |
F |
2.16.840.1.113883.10.20.22.4.119 |
|
|
hl7:time
|
|
|
1 .. 1 |
M |
|
conf‑31471 |
|
|
hl7:assignedAuthor
|
|
|
1 .. 1 |
M |
|
conf‑31472 |
|
|
|
1 .. 1 |
M |
Note: This id may be set equal to (a pointer to) an id on a participant elsewhere
in the document (header or entries) or a new author participant can be described here.
If the id is pointing to a participant already described elsewhere in the document,
assignedAuthor/id is sufficient to identify this participant and none of the remaining
details of
assignedAuthor are required to be set. Application Software must be responsible for
resolving the identifier back to its original object and then rendering the information
in the correct place in the containing section's narrative text. |
conf‑31473 |
|
|
|
0 .. 1 |
|
|
conf‑31472 |
|
CONF |
| De waarde van @code moet komen uit waardelijst 2.16.840.1.114222.4.11.1066 Healthcare Provider Taxonomy (HIPAA) (DYNAMISCH) |
| moet codeersterkte "CWE" hebben |
|
|
|
|
0 .. 1 |
|
|
conf‑31474 |
|
|
PN |
0 .. * |
|
|
conf‑31475 |
|
|
|
hl7:representedOrganization
|
|
|
0 .. 1 |
|
|
conf‑31476 |
|
|
|
1 .. 1 |
F |
ORG |
|
|
II |
0 .. * |
|
|
conf‑31478 |
|
|
ON |
0 .. * |
|
|
conf‑31479 |
|
|
TEL |
0 .. * |
|
|
conf‑31480 |
|
|
AD |
0 .. * |
|
|
conf‑31481 |
|
hl7:referenceRange
|
|
|
0 .. * |
R |
|
conf‑7150 |
|
|
hl7:observationRange
|
|
|
1 .. 1 |
M |
|
conf‑7151 |
|
|
|
|
|
|
conf‑7152 |
|
Schematron assert |
role |
 error
|
|
test |
not(cda:referenceRange/cda:observationRange/cda:code) |
|
Melding |
This observationRange SHALL NOT contain [0..0] code (CONF:7152). |
|
Template CCDA2 Result Observation