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pending Template  CCDA2 Result Observation

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
Versie geldig vanaf 2013‑01‑31 status pending Onder revisie vóór de publicatie
Classificatie CDA entry level template
Context Parent nodes van template element met id 2.16.840.1.113883.10.20.22.4.2.2
Open/gesloten Open (ook andere dan gedefinieerde elementen zijn toegestaan)
Omschrijving en-US 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
Gebruikt Template-id als Naam Versie
2.16.840.1.113883.10.20.22.4.119 Inclusie ccda2-AuthorParticipation DYNAMISCH
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
hl7:observation
(ccda2-ResultObservation)
treetree @classCode
1 .. 1 F OBS
treetree @moodCode
1 .. 1 F EVN
treetree hl7:templateId
1 .. 1 M conf‑7136
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.2.2
treetree hl7:id
1 .. * M conf‑7137
treetree hl7:code
1 .. 1 M conf‑7133
  Constraint en-US 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 en-US 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)
treetree hl7:text
0 .. 1 R conf‑7138
treeblank treetree hl7:reference
0 .. 1 R conf‑15924
treeblank treeblank treetree @value
0 .. 1  
treetree hl7:statusCode
1 .. 1 M conf‑7134
  CONF
De waarde van @code moet komen uit waardelijst 2.16.840.1.113883.11.20.9.39 Result Status (DYNAMISCH)
treetree hl7:effectiveTime
1 .. 1 M conf‑7140
treetree hl7:value
1 .. 1 M conf‑7143
treetree hl7:interpretationCode
0 .. * R conf‑7147
treetree hl7:methodCode
CE 0 .. 1 conf‑7148
treetree hl7:targetSiteCode
CD 0 .. 1 conf‑7153
Ingevoegd van 2.16.840.1.113883.10.20.22.4.119 CCDA2 Author Participation (DYNAMISCH) 0..*
treetree hl7:author
0 .. * conf‑7149
treeblank treetree hl7:templateId
1 .. 1 M conf‑32017
treeblank treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.119
treeblank treetree hl7:time
1 .. 1 M conf‑31471
treeblank treetree hl7:assignedAuthor
1 .. 1 M conf‑31472
treeblank treeblank treetree hl7:id
1 .. 1 M en-US 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
treeblank treeblank treetree hl7:code
CWE 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)
treeblank treeblank treetree hl7:assignedPerson
0 .. 1 conf‑31474
treeblank treeblank treeblank treetree hl7:name
PN 0 .. * conf‑31475
treeblank treeblank treetree hl7:representedOrganization
0 .. 1 conf‑31476
treeblank treeblank treeblank treetree @classCode
1 .. 1 F ORG
treeblank treeblank treeblank treetree hl7:id
II 0 .. * conf‑31478
treeblank treeblank treeblank treetree hl7:name
ON 0 .. * conf‑31479
treeblank treeblank treeblank treetree hl7:telecom
TEL 0 .. * conf‑31480
treeblank treeblank treeblank treetree hl7:addr
AD 0 .. * conf‑31481
treetree hl7:referenceRange
0 .. * R conf‑7150
treeblank treetree hl7:observationRange
1 .. 1 M conf‑7151
treeblank treeblank treetree hl7:code
conf‑7152
  Schematron assert role red error
  test not(cda:referenceRange/cda:observationRange/cda:code)
  Melding This observationRange SHALL NOT contain [0..0] code (CONF:7152).