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ref Template  Laboratory Observation

Id 1.3.6.1.4.1.19376.1.3.1.6 ref (van repository: iheptv-) Geldigheid geldig vanaf 2008‑08‑08
Status review Wordt gereviewed Versielabel
Naam LaboratoryObservation Weergavenaam Laboratory Observation
Omschrijving en-US 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.
Context Parent nodes van template element met id 1.3.6.1.4.1.19376.1.3.1.6
Classificatie CDA entry level template
Open/gesloten Open (ook andere dan gedefinieerde elementen zijn toegestaan)
Gebruikt door / Gebruikt
Gebruikt door 1 template, Gebruikt 6 templates
Gebruikt door Template-id als Naam Versie
1.3.6.1.4.1.19376.1.3.1.6 Containment Laboratory Observation 2008‑08‑08
Gebruikt Template-id als Naam Versie
1.3.6.1.4.1.19376.1.3.3.1.2.1 Containment NonHumanSubject DYNAMISCH
1.3.6.1.4.1.19376.1.3.3.1.3.1 Containment Humanpatientwithnonhumansubject DYNAMISCH
2.16.840.1.113883.10.12.323 Containment CDAPerformerBody DYNAMISCH
2.16.840.1.113883.10.12.318 Containment CDAAuthorBody DYNAMISCH
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
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
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">
    <!-- 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>
Item DT Card Conf Omschrijving Label
hl7:observation
1 … 1 M (LaboratoryObservation)
@classCode
1 … 1 F OBS
@moodCode
1 … 1 F EVN
hl7:templateId
II 1 … 1 M (LaboratoryObservation)
@root
1 … 1 F 1.3.6.1.4.1.19376.1.3.1.6
hl7:id
II 0 … 1 en-US A Laboratory Observation identifier MAY be present. (LaboratoryObservation)
hl7:code
CE 1 … 1 R en-US Unique test code in an international standard (LOINC or SNOMED CT) or a national standard (e.g. JC10 in Japan) (LaboratoryObservation)
hl7:statusCode
CS 1 … 1 M en-US ‘completed’ when the result is present.
‘aborted’ if the test could not be performed.
(LaboratoryObservation)
  CONF
@code moet "completed" zijn
of
@code moet "aborted" zijn
hl7:effectiveTime
TS 0 … 1 R en-US Physiologically relevant time (LaboratoryObservation)
hl7:value
ANY 0 … 1 R en-US The 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. (LaboratoryObservation)
@xsi:type
1 … 1 F ANY
hl7:interpretationCode
CE 0 … 1 R en-US One 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
(LaboratoryObservation)
  CONF
moet uit concept domein "Observation Interpretation" worden gekozen
hl7:methodCode
CE 0 … 1 R en-US method used for this observation expressed with ObservationMethod vocabulary (CWE) (LaboratoryObservation)
  CONF
moet uit concept domein "Observation Method" worden gekozen
Keuze  … 1 Elementen om uit te kiezen:
hl7:subject
0 … 1 en-US subject in case of a non-human subject attached to the isolate
Bevat 1.3.6.1.4.1.19376.1.3.3.1.2.1 Non-Human Subject (DYNAMISCH)
(LaboratoryObservation)
waar [hl7:subject [hl7:templateId/@root='1.3.6.1.4.1.19376.1.3.3.1.2.1']]
@typeCode
0 … 1 F SBJ
hl7:subject
0 … 1 en-US subject in case of a non-human subject attached to the isolate
Bevat 1.3.6.1.4.1.19376.1.3.3.1.3.1 Human Patient with Non-Human Subject (DYNAMISCH)
(LaboratoryObservation)
waar [hl7:subject [hl7:templateId/@root='1.3.6.1.4.1.19376.1.3.3.1.3.1']]
@typeCode
0 … 1 F SBJ
hl7:specimen
0 … 1 R en-US specimen participation if this observation uses a specific specimen not recorded at a higher level. (LaboratoryObservation)
@typeCode
1 … 1 F SPC
hl7:specimenRole
0 … 1 (LaboratoryObservation)
@classCode
1 … 1 F SPEC
hl7:id
II 0 … 1 en-US specimen identifier known to the laboratory (LaboratoryObservation)
hl7:specimenPlayingEntity
1 … 1 (LaboratoryObservation)
hl7:code
CE 1 … 1 M en-US 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 en-US Extension to CDA Clinical Statement (LaboratoryObservation)
@typeCode
1 … 1 F 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 F PROC
@moodCode
1 … 1 F EVN
lab:code
CE 0 … 1 (LaboratoryObservation)
lab:effectiveTime
IVL_TS 1 … 1 M (LaboratoryObservation)
lab:targetSiteCode
CD 0 … * (LaboratoryObservation)
hl7:performer
0 … 1 R en-US performer participation. Performer to supersede those recorded at higher level.
Bevat 2.16.840.1.113883.10.12.323 CDA Performer (Body) (DYNAMISCH)
(LaboratoryObservation)
@typeCode
1 … 1 F PRF
hl7:author
0 … * R en-US author participation used to supersede the authors of higher level.
Bevat 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMISCH)
(LaboratoryObservation)
@typeCode
1 … 1 F AUT
Keuze  … 3 Elementen om uit te kiezen:
  • hl7:participant[@typeCode='AUTHEN']
  • hl7:participant[@typeCode='RESP']
  • hl7:participant[@typeCode='DEV']
hl7:participant
0 … 1 en-US Other 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.
(LaboratoryObservation)
waar [@typeCode='AUTHEN']
@typeCode
1 … 1 F AUTHEN
hl7:participant
0 … 1 en-US Other 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.
(LaboratoryObservation)
waar [@typeCode='RESP']
@typeCode
1 … 1 F RESP
hl7:participant
0 … 1 en-US Other participants "AUTHEN", "RESP", and "DEV".
  • DEV: A device or equipment, which was used to produce this battery of results (e.g. an analyzer).
(LaboratoryObservation)
waar [@typeCode='DEV']
@typeCode
1 … 1 F DEV
hl7:entryRelationship
0 … * R en-US Comment on this Observation
Bevat 1.3.6.1.4.1.19376.1.5.3.1.4.2 Annotation Comment (DYNAMISCH)
(LaboratoryObservation)
waar [@typeCode='COMP']
@typeCode
1 … 1 F COMP
hl7:entryRelationship
0 … * R en-US Previous observations obtained for the same patient, test, same method, same unit (1)
Bevat 1.3.6.1.4.1.19376.1.3.1.6 Laboratory Observation (DYNAMISCH)
(LaboratoryObservation)
waar [@typeCode='REFR']
@typeCode
1 … 1 F REFR
hl7:sequenceNumber
INT 0 … 1 R (LaboratoryObservation)
  Schematron assert role red error  
  test hl7:observation/hl7:statusCode[@code='completed']  
  Melding Status code of previous observations must be 'completed'  
hl7:referenceRange
0 … 1 R en-US Reference range for the current test result (LaboratoryObservation)
@typeCode
1 … 1 F REFV
hl7:observationRange
1 … 1 M (LaboratoryObservation)
@classCode
1 … 1 F OBS
@moodCode
1 … 1 F EVN.CRT
hl7:value
0 … 1 interval (IVL) representation (LaboratoryObservation)
hl7:interpretationCode
CV 1 … 1 R (LaboratoryObservation)
@code
1 … 1 F N
@codeSystem
1 … 1 F 2.16.840.1.113883.5.83 (Observation Interpretation)
lab:precondition
0 … * en-US Extension to CDA Clinical statement (LaboratoryObservation)
@typeCode
1 … 1 F PRCN
lab:criterion
1 … 1 (LaboratoryObservation)
@classCode
1 … 1 F COND
@moodCode
1 … 1 F EVN
lab:code
CE 1 … 1 R en-US Code of the criterion (e.g. age, sex) (LaboratoryObservation)
lab:value
1 … 1 R Value of the criterion (LaboratoryObservation)