Item |
DT |
Card |
Conf |
Omschrijving |
Label |
|
|
1 .. 1 |
M |
|
(gebb-LaboratoryObservation) |
|
@classCode
|
|
|
1 .. 1 |
F |
OBS |
|
@moodCode
|
|
|
1 .. 1 |
F |
EVN |
|
hl7:templateId
|
|
II |
1 .. 1 |
M |
|
(gebb-LaboratoryObservation) |
|
|
@root
|
|
|
1 .. 1 |
F |
2.16.840.1.113883.2.4.3.11.60.2.10.5 |
|
hl7:id
|
|
II |
0 .. 1 |
|
A Laboratory Observation identifier MAY be present. |
(gebb-LaboratoryObservation) |
|
hl7:code
|
|
CE |
1 .. 1 |
M |
A Laboratory Observation SHALL contain a unique test code from an international standard,
such as LOINC. |
(gebb-LaboratoryObservation) |
|
hl7:text
|
|
ED |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
hl7:statusCode
|
|
CS |
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.
|
(gebb-LaboratoryObservation) |
|
CONF |
@code moet "active" zijn |
of |
@code moet "completed" zijn |
of |
@code moet "aborted" zijn |
|
|
hl7:effectiveTime
|
|
TS |
0 .. 1 |
R |
A Laboratory Observation MAY contain a relevant clinical time (ideally specimen collection
time). |
(gebb-LaboratoryObservation) |
|
hl7:value
|
|
ANY |
0 .. 1 |
R |
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. |
(gebb-LaboratoryObservation) |
|
hl7:interpretationCode
|
|
CE |
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. |
(gebb-LaboratoryObservation) |
|
CONF |
|
|
hl7:methodCode
|
|
CE |
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. |
(gebb-LaboratoryObservation) |
|
hl7:targetSiteCode
|
|
CD |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
CONF |
moet uit concept domein "Act Site" worden gekozen |
|
|
hl7:subject
|
|
|
0 .. 1 |
|
Subject in case of a non-human subject attached to the Observation |
(gebb-LaboratoryObservation) |
Ingevoegd van 2.16.840.1.113883.2.4.3.11.60.66.10.9010 PART CDA Subject (Body) (DYNAMISCH)
|
|
|
@typeCode
|
|
|
0 .. 1 |
F |
SBJ |
|
|
@contextControlCode
|
|
|
0 .. 1 |
F |
OP |
|
|
hl7:awarenessCode
|
|
CE |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CONF |
|
|
|
hl7:relatedSubject
|
|
|
1 .. 1 |
R |
|
(gebb-LaboratoryObservation) |
|
cs |
1 .. 1 |
R |
|
|
CONF |
|
|
CE |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CONF |
|
|
AD |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
TEL |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
|
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
|
0 .. 1 |
F |
PSN |
|
|
0 .. 1 |
F |
INSTANCE |
|
PN |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
|
|
|
hl7:administrativeGenderCode
|
|
CE |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CONF |
|
|
TS |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
hl7:specimen
|
|
|
0 .. 1 |
|
A Laboratory Observation MAY contain specimen documentation when it is different from
the one documented at a higher level. |
(gebb-LaboratoryObservation) |
Ingevoegd van 2.16.840.1.113883.2.4.3.11.60.66.10.9006 PART CDA Specimen (DYNAMISCH)
|
|
|
@typeCode
|
|
|
0 .. 1 |
F |
SPC |
|
|
hl7:specimenRole
|
|
|
1 .. 1 |
R |
|
(gebb-LaboratoryObservation) |
|
|
0 .. 1 |
F |
SPEC |
|
II |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
|
|
hl7:specimenPlayingEntity
|
|
|
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
|
0 .. 1 |
F |
ENT |
|
|
0 .. 1 |
F |
INSTANCE |
|
CE |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CONF |
|
|
PQ |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
PN |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
ED |
0 .. 1 |
|
|
(gebb-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. |
(gebb-LaboratoryObservation) |
Ingevoegd van 2.16.840.1.113883.2.4.3.11.60.66.10.9012 PART CDA Performer (Body) (DYNAMISCH)
|
|
|
@typeCode
|
|
|
0 .. 1 |
F |
PRF |
|
|
hl7:time
|
|
IVL_TS |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
|
hl7:modeCode
|
|
CE |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CONF |
|
|
|
hl7:assignedEntity
|
|
|
1 .. 1 |
R |
|
(gebb-LaboratoryObservation) |
Ingevoegd van 2.16.840.1.113883.2.4.3.11.60.66.10.9003 PART CDA Assigned Entity (DYNAMISCH)
|
|
II |
1 .. * |
|
|
(gebb-LaboratoryObservation) |
|
CE |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CONF |
moet uit concept domein "Role Code" worden gekozen |
|
|
AD |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
TEL |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
|
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
Ingevoegd van 2.16.840.1.113883.2.4.3.11.60.66.10.9001 PART CDA Person (DYNAMISCH)
|
|
|
0 .. 1 |
F |
PSN |
|
|
0 .. 1 |
F |
INSTANCE |
|
PN |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
|
Gekoppeld aan concepten:
|
|
|
|
hl7:representedOrganization
|
|
|
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
Ingevoegd van 2.16.840.1.113883.2.4.3.11.60.66.10.9002 PART CDA Organization (DYNAMISCH)
|
|
|
0 .. 1 |
F |
ORG |
|
|
0 .. 1 |
F |
INSTANCE |
|
|
|
|
hl7:id waar [@root='2.16.528.1.1007.3.3'] |
|
II.NL.URA |
1 .. 1 |
R |
Minst een id moet een URA zijn |
(gebb-LaboratoryObservation) |
|
|
1 .. 1 |
F |
2.16.528.1.1007.3.3 |
|
II |
0 .. * |
|
Andere IDs |
(gebb-LaboratoryObservation) |
|
Voorbeeld |
<id root="2.16.840.1.113883.2.4.3.23.3.1234"/>
|
|
ON |
1 .. 1 |
R |
|
(gebb-LaboratoryObservation) |
|
TEL |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
AD |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
|
|
|
hl7:standardIndustryClassCode
|
|
CE |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CONF |
moet uit concept domein "Organization Industry Class" worden gekozen |
|
|
hl7:author
|
|
|
0 .. * |
R |
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. |
(gebb-LaboratoryObservation) |
Ingevoegd van 2.16.840.1.113883.2.4.3.11.60.66.10.9011 PART CDA Author (Body) (DYNAMISCH)
|
|
|
@typeCode
|
|
|
0 .. 1 |
F |
AUT |
|
|
@contextControlCode
|
|
|
0 .. 1 |
F |
OP |
|
|
hl7:functionCode
|
|
CD |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CONF |
moet uit concept domein "Participation Function" worden gekozen |
|
|
|
hl7:time
|
|
TS |
1 .. 1 |
R |
|
(gebb-LaboratoryObservation) |
|
|
hl7:assignedAuthor
|
|
|
1 .. 1 |
R |
|
(gebb-LaboratoryObservation) |
|
|
0 .. 1 |
F |
ASSIGNED |
|
II |
1 .. * |
R |
|
(gebb-LaboratoryObservation) |
|
CE |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CONF |
moet uit concept domein "Role Code" worden gekozen |
|
|
AD |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
TEL |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
Keuze min 0 element(en) en max * element(en). Elementen om uit te kiezen:
- hl7:assignedPerson met hl7:name uit template PART CDA Person (DYNAMISCH)
- hl7:assignedAuthoringDevice met hl7:code uit template PART CDA Device (DYNAMISCH)
|
|
|
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
Bevat |
2.16.840.1.113883.2.4.3.11.60.66.10.9001 PART CDA Person (DYNAMISCH)
|
|
|
|
|
hl7:assignedAuthoringDevice
|
|
|
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
Bevat |
2.16.840.1.113883.2.4.3.11.60.66.10.9008 PART CDA Device (DYNAMISCH)
|
|
|
|
hl7:representedOrganization
|
|
|
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
Bevat |
2.16.840.1.113883.2.4.3.11.60.66.10.9002 PART CDA Organization (DYNAMISCH)
|
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. |
(gebb-LaboratoryObservation) |
|
|
1 .. 1 |
F |
AUTHEN |
Ingevoegd van 2.16.840.1.113883.2.4.3.11.60.66.10.9007 PART CDA Participant (Body) (DYNAMISCH)
|
|
cs |
1 .. 1 |
R |
|
|
CONF |
|
|
|
1 .. 1 |
F |
OP |
|
IVL_TS |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CE |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CONF |
|
|
|
1 .. 1 |
R |
|
(gebb-LaboratoryObservation) |
|
|
0 .. 1 |
F |
ROL |
|
II |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
CE |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
|
1 .. 1 |
F |
2.16.840.1.113883.5.111 (RoleCode) |
|
AD |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
TEL |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
Keuze min 0 element(en) en max * element(en). Elementen om uit te kiezen:
|
|
|
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
Bevat |
2.16.840.1.113883.2.4.3.11.60.66.10.9008 PART CDA Device (DYNAMISCH)
|
|
|
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
Bevat |
2.16.840.1.113883.2.4.3.11.60.66.10.9009 PART CDA PlayingEntity (DYNAMISCH)
|
|
|
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
|
0 .. 1 |
F |
ENT |
|
|
0 .. 1 |
F |
INSTANCE |
|
II |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
CE |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CONF |
|
|
ED |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
|
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. |
(gebb-LaboratoryObservation) |
|
|
1 .. 1 |
F |
RESP |
Ingevoegd van 2.16.840.1.113883.2.4.3.11.60.66.10.9007 PART CDA Participant (Body) (DYNAMISCH)
|
|
cs |
1 .. 1 |
R |
|
|
CONF |
|
|
|
1 .. 1 |
F |
OP |
|
IVL_TS |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CE |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CONF |
|
|
|
1 .. 1 |
R |
|
(gebb-LaboratoryObservation) |
|
|
0 .. 1 |
F |
ROL |
|
II |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
CE |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
|
1 .. 1 |
F |
2.16.840.1.113883.5.111 (RoleCode) |
|
AD |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
TEL |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
Keuze min 0 element(en) en max * element(en). Elementen om uit te kiezen:
|
|
|
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
Bevat |
2.16.840.1.113883.2.4.3.11.60.66.10.9008 PART CDA Device (DYNAMISCH)
|
|
|
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
Bevat |
2.16.840.1.113883.2.4.3.11.60.66.10.9009 PART CDA PlayingEntity (DYNAMISCH)
|
|
|
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
|
0 .. 1 |
F |
ENT |
|
|
0 .. 1 |
F |
INSTANCE |
|
II |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
CE |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CONF |
|
|
ED |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
|
hl7:participant waar [@typeCode='DEV'] |
|
|
0 .. 1 |
|
A device or equipment, which was used to produce this set of results (e.g. an analyzer). |
(gebb-LaboratoryObservation) |
|
|
1 .. 1 |
F |
DEV |
Ingevoegd van 2.16.840.1.113883.2.4.3.11.60.66.10.9007 PART CDA Participant (Body) (DYNAMISCH)
|
|
cs |
1 .. 1 |
R |
|
|
CONF |
|
|
|
1 .. 1 |
F |
OP |
|
IVL_TS |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CE |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CONF |
|
|
|
1 .. 1 |
R |
|
(gebb-LaboratoryObservation) |
|
|
0 .. 1 |
F |
ROL |
|
II |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
CE |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
|
1 .. 1 |
F |
2.16.840.1.113883.5.111 (RoleCode) |
|
AD |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
TEL |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
Keuze min 0 element(en) en max * element(en). Elementen om uit te kiezen:
|
|
|
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
Bevat |
2.16.840.1.113883.2.4.3.11.60.66.10.9008 PART CDA Device (DYNAMISCH)
|
|
|
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
Bevat |
2.16.840.1.113883.2.4.3.11.60.66.10.9009 PART CDA PlayingEntity (DYNAMISCH)
|
|
|
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
|
0 .. 1 |
F |
ENT |
|
|
0 .. 1 |
F |
INSTANCE |
|
II |
0 .. * |
|
|
(gebb-LaboratoryObservation) |
|
CE |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
CONF |
|
|
ED |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
hl7:entryRelationship waar [@typeCode='COMP'] |
|
|
0 .. * |
R |
A Laboratory Observation MAY contain test comments that shall be recorded using the
Annotation Comment template within the Laboratory Observation as shown above. |
(gebb-LaboratoryObservation) |
|
|
@typeCode
|
|
|
1 .. 1 |
F |
COMP |
|
Bevat |
2.16.840.1.113883.2.4.3.11.60.2.10.6 GEBB Comment Activity (DYNAMISCH)
|
|
hl7:entryRelationship waar [@typeCode='REFR'] |
|
|
0 .. * |
R |
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. |
(gebb-LaboratoryObservation) |
|
|
@typeCode
|
|
|
1 .. 1 |
F |
REFR |
|
Bevat |
2.16.840.1.113883.2.4.3.11.60.2.10.5 GEBB Laboratory Observation (DYNAMISCH)
|
Ingevoegd van 2.16.840.1.113883.2.4.3.11.60.66.10.9005 PART CDA Observation Reference Range (DYNAMISCH) 0..1
|
|
hl7:referenceRange
|
|
|
0 .. 1 |
|
Referentiewaarden |
(gebb-LaboratoryObservation) |
|
|
@typeCode
|
|
|
1 .. 1 |
F |
REFV |
|
|
Gekoppeld aan concepten:
|
|
Voorbeeld |
Reference range with preconditions <referenceRange typeCode="REFV"> <observationRange classCode="OBS" moodCode="EVN.CRT"> <text>43.0 - 49.0</text> <value xsi:type="IVL_PQ"> <low value="43.0" unit="%"/> <high value="49.0" unit="%"/> </value> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" codeSystemName="ObservationInterpretation"/> </observationRange></referenceRange> |
|
Voorbeeld |
Reference range with preconditions <referenceRange typeCode="REFV"> <observationRange classCode="OBS" moodCode="EVN.CRT"> <text>>40</text> <value xsi:type="IVL_PQ"> <low value="40.0" unit="%" inclusive="false"/> </value> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" codeSystemName="ObservationInterpretation"/> </observationRange></referenceRange> |
|
|
hl7:observationRange
|
|
|
1 .. 1 |
M |
|
(gebb-LaboratoryObservation) |
|
|
1 .. 1 |
F |
OBS |
|
|
1 .. 1 |
F |
EVN.CRT |
|
|
|
NP |
|
(gebb-LaboratoryObservation) |
|
ED |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
|
Gekoppeld aan concepten:
|
|
IVL_PQ |
0 .. 1 |
|
|
(gebb-LaboratoryObservation) |
|
PQ |
1 .. 1 |
R |
|
(gebb-LaboratoryObservation) |
|
|
Gekoppeld aan concepten:
|
|
PQ |
1 .. 1 |
R |
|
(gebb-LaboratoryObservation) |
|
|
Gekoppeld aan concepten:
|
|
CV |
1 .. 1 |
M |
|
(gebb-LaboratoryObservation) |
|
|
1 .. 1 |
F |
N |
|
|
1 .. 1 |
F |
2.16.840.1.113883.5.83 (Observation Interpretation) |
|
|
Gekoppeld aan concepten:
|