Template 1.3.6.1.4.1.19376.1.3.1.6 - LaboratoryObservation

Template Laboratory Observation

Template 1.3.6.1.4.1.19376.1.3.1.6 - LaboratoryObservation ref (van repository: iheptv-)

Id 1.3.6.1.4.1.19376.1.3.1.6

Versie geldig vanaf 2008‑08‑08 status Onder revisie vóór de publicatie

Classificatie CDA entry level template

Context Parent nodes van template element met id 1.3.6.1.4.1.19376.1.3.1.6

Open/gesloten Open (ook andere dan gedefinieerde elementen zijn toegestaan)

Omschrijving 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.

Gebruikt door / Gebruikt

Gebruikt door / Gebruikt 5 templates

Gebruikt door Template-id	als	Naam	Versie
1.3.6.1.4.1.19376.1.3.1.6	Containment	LaboratoryObservation Laboratory Observation	2008‑08‑08
Gebruikt Template-id	als	Naam	Versie
1.3.6.1.4.1.19376.1.5.3.1.4.2	Containment	AnnotationComment	DYNAMISCH

Relatie Specialisatie: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)

Voorbeeld <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>

Voorbeeld <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">  <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>  <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>

Item DT Card Conf Omschrijving Label

hl7:observation

1 .. 1

(LaboratoryObservation)

@classCode

1 .. 1

OBS

@moodCode

1 .. 1

EVN

hl7:templateId

1 .. 1

(LaboratoryObservation)

@root

1 .. 1

1.3.6.1.4.1.19376.1.3.1.6

hl7:id

0 .. 1

A Laboratory Observation identifier MAY be present.

(LaboratoryObservation)

hl7:code

1 .. 1

A Laboratory Observation SHALL contain a unique test code from an international standard, such as LOINC.

(LaboratoryObservation)

hl7:statusCode

1 .. 1

A Laboratory Observation statusCode SHALL be either "completed" or "aborted".

A status of completed means the test was performed and results obtained.
A status of aborted means the test could not be performed and has no value.

(LaboratoryObservation)

CONF

@code moet "completed" zijn

@code moet "aborted" zijn

hl7:effectiveTime

0 .. 1

A Laboratory Observation MAY contain a relevant clinical time (ideally specimen collection time).

(LaboratoryObservation)

hl7:value

ANY

0 .. 1

A Laboratory Observation value using the appropriate data type MAY be present. Numeric results shall use data type "PQ" as shown above as it includes units. The result is absent in the case of "aborted" observations.

(LaboratoryObservation)

hl7:interpretationCode

0 .. 1

A Laboratory Observation MAY contain an interpretation of the Laboratory Observation result (e.g., low, high). One or more ObservationInterpretation vocabulary MAY be recorded within the interpretationCode element.

(LaboratoryObservation)

hl7:methodCode

0 .. 1

A Laboratory Observation MAY contain a methodCode using the Observation Method vocabulary (CWE). The method MAY be explicit when LOINC vocabulary is used for the Laboratory Observation code.

(LaboratoryObservation)

hl7:subject

0 .. 1

Subject in case of a non-human subject attached to the Observation

(LaboratoryObservation)

@typeCode

1 .. 1

SBJ

hl7:specimen

0 .. 1

A Laboratory Observation MAY contain specimen documentation when it is different from the one documented at a higher level.

(LaboratoryObservation)

@typeCode

1 .. 1

SPC

hl7:specimenRole

0 .. 1

(LaboratoryObservation)

@classCode

1 .. 1

SPEC

Voorbeeld <specimen typeCode="SPC"> <specimenRole classCode="SPEC">  <id root="1.3.6.4.1.4.1.2835.1" extension="0321123456"/>  <specimenPlayingEntity>  </specimenPlayingEntity> <lab:productOf typeCode="PRD">  </lab:productOf> </specimenRole></specimen>

hl7:id

0 .. 1

specimen identifier known to the laboratory

(LaboratoryObservation)

hl7:specimenPlayingEntity

1 .. 1

(LaboratoryObservation)

Voorbeeld <specimenPlayingEntity> <code code="BLDV" codeSystem="2.16.840.1.113883.XXX.YYY" displayName="blood venous"/> </specimenPlayingEntity>

hl7:code

1 .. 1

The specimen type coded with HL7 vocabulary SpecimenEntityType or another standard vocabulary

(LaboratoryObservation)

CONF

moet uit concept domein "Specimen Entity Type" worden gekozen

lab:productOf

0 .. 1

Extension to CDA Clinical Statement

(LaboratoryObservation)

@typeCode

1 .. 1

PRD

Voorbeeld <lab:productOf typeCode="PRD"> <lab:procedure classCode="PROC" moodCode="EVN">  <lab:effectiveTime value="200603210630"/> </lab:procedure></lab:productOf>

lab:procedure

(LaboratoryObservation)

@classCode

1 .. 1

PROC

@moodCode

1 .. 1

EVN

lab:code

0 .. 1

(LaboratoryObservation)

lab:effectiveTime

IVL_TS

1 .. 1

(LaboratoryObservation)

lab:targetSiteCode

0 .. *

(LaboratoryObservation)

hl7:performer

0 .. 1

A Laboratory Observation MAY contain the person who performed the test when it is different from the one documented at a higher level, including the header.

(LaboratoryObservation)

@typeCode

1 .. 1

PRF

hl7:author

0 .. *

A Laboratory Observation SHALL contain author(s) of the Laboratory Observation when multiple header author(s) exist and not all apply to this Laboratory Observation. The author/time element carries the date&time the laboratory report was produced by the system.

(LaboratoryObservation)

@typeCode

1 .. 1

AUT

Keuze max 3 element(en). Elementen om uit te kiezen:

hl7:participant[@typeCode='AUTHEN']
hl7:participant[@typeCode='RESP']
hl7:participant[@typeCode='DEV']

hl7:participant
waar
[@typeCode='AUTHEN']

0 .. 1

The verifier of the observations of this part of the report. In the case where a laboratory report has multiple verifiers. Each verifier is attached to the subset of observations he or she verified, by the means of a <participant> element.

(LaboratoryObservation)

@typeCode

1 .. 1

AUTHEN

hl7:participant
waar
[@typeCode='RESP']

0 .. 1

The person responsible for the provision of the observations of this part of the report. In the case where a subset of the observations 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.

(LaboratoryObservation)

@typeCode

1 .. 1

RESP

hl7:participant
waar
[@typeCode='DEV']

0 .. 1

A device or equipment, which was used to produce this set of results (e.g. an analyzer).

(LaboratoryObservation)

@typeCode

1 .. 1

DEV

hl7:entryRelationship
waar
[@typeCode='COMP']

0 .. *

A Laboratory Observation MAY contain test comments that shall be recorded using the Annotation Comment template within the Laboratory Observation as shown above.

(LaboratoryObservation)

@typeCode

1 .. 1

COMP

Bevat 1.3.6.1.4.1.19376.1.5.3.1.4.2 Annotation Comment (DYNAMISCH)

hl7:entryRelationship
waar
[@typeCode='REFR']

0 .. *

A Laboratory Observation MAY be complemented by any number of previous results as pertinent information related to it delivering the previous result from a separate specimen, and carrying the same test code. In case there is more than one previous result, the entryRelationship elements are sorted in reverse chronological order, numbered from 1 to n by sequenceNumber.

(LaboratoryObservation)

@typeCode

1 .. 1

REFR

Bevat 1.3.6.1.4.1.19376.1.3.1.6 Laboratory Observation (DYNAMISCH)

hl7:referenceRange

0 .. 1

A Laboratory Observation MAY have a reference range representing a value, not text. The reference range MAY be qualified with pre-conditions, each of which has a criterion.

(LaboratoryObservation)

@typeCode

1 .. 1

REFV

hl7:observationRange

1 .. 1

(LaboratoryObservation)

@classCode

1 .. 1

OBS

@moodCode

1 .. 1

EVN.CRT

hl7:value

0 .. 1

interval (IVL) representation

(LaboratoryObservation)

hl7:interpretationCode

1 .. 1

(LaboratoryObservation)

@code

1 .. 1

@codeSystem

1 .. 1

2.16.840.1.113883.5.83 (Observation Interpretation)

lab:precondition

0 .. *

Extension to CDA Clinical statement

(LaboratoryObservation)

@typeCode

1 .. 1

PRCN

lab:criterion

1 .. 1

(LaboratoryObservation)

@classCode

1 .. 1

COND

@moodCode

1 .. 1

EVN

lab:code

1 .. 1

Code of the criterion (e.g. age, sex)

(LaboratoryObservation)

lab:value

1 .. 1

Value of the criterion

(LaboratoryObservation)

Template Laboratory Observation