hl7:observation
|
|
1 … 1 |
M |
|
(geb ion) |
@classCode
|
|
1 … 1 |
F |
OBS |
@moodCode
|
|
1 … 1 |
F |
EVN |
hl7:templateId
|
II |
1 … 1 |
M |
|
(gebion) |
@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. |
(gebion) |
hl7:code
|
CE |
1 … 1 |
M |
A Laboratory Observation SHALL contain a unique test code from an international standard,
such as LOINC. |
(gebion) |
hl7:text
|
ED |
0 … 1 |
|
|
(gebion) |
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.
|
(gebion) |
| |
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). |
(gebion) |
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. |
(gebion) |
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. |
(gebion) |
| |
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. |
(gebion) |
hl7:targetSiteCode
|
CD |
0 … * |
|
|
(gebion) |
| |
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 |
(gebion) |
| Inclusie |
|
|
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 |
|
|
(gebion) |
| |
CONF |
|
hl7:relatedSubject
|
|
1 … 1 |
R |
|
(gebion) |
@classCode
|
cs |
1 … 1 |
R |
|
| |
CONF |
|
hl7:code
|
CE |
0 … 1 |
|
|
(gebion) |
| |
CONF |
|
hl7:addr
|
AD |
0 … * |
|
|
(gebion) |
hl7:telecom
|
TEL |
0 … * |
|
|
(gebion) |
hl7:subject
|
|
0 … 1 |
|
|
(gebion) |
@classCode
|
|
0 … 1 |
F |
PSN |
@determinerCode
|
|
0 … 1 |
F |
INSTANCE |
hl7:name
|
PN |
0 … * |
|
|
(gebion) |
hl7:administrativeGenderCode
|
CE |
0 … 1 |
|
|
(gebion) |
| |
CONF |
|
hl7:birthTime
|
TS |
0 … 1 |
|
|
(gebion) |
hl7:specimen
|
|
0 … 1 |
|
A Laboratory Observation MAY contain specimen documentation when it is different from
the one documented at a higher level. |
(gebion) |
| Inclusie |
|
|
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 |
|
(gebion) |
@classCode
|
|
0 … 1 |
F |
SPEC |
hl7:id
|
II |
0 … * |
|
|
(gebion) |
hl7:specimenPlayingEntity
|
|
0 … 1 |
|
|
(gebion) |
@classCode
|
|
0 … 1 |
F |
ENT |
@determinerCode
|
|
0 … 1 |
F |
INSTANCE |
hl7:code
|
CE |
0 … 1 |
|
|
(gebion) |
| |
CONF |
|
hl7:quantity
|
PQ |
0 … * |
|
|
(gebion) |
hl7:name
|
PN |
0 … * |
|
|
(gebion) |
hl7:desc
|
ED |
0 … 1 |
|
|
(gebion) |
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. |
(gebion) |
| Inclusie |
|
|
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 |
|
|
(gebion) |
hl7:modeCode
|
CE |
0 … 1 |
|
|
(gebion) |
| |
CONF |
|
hl7:assignedEntity
|
|
1 … 1 |
R |
|
(gebion) |
| Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.11.60.66.10.9003 PART CDA Assigned Entity (DYNAMISCH)
|
hl7:id
|
II |
1 … * |
|
|
(gebion) |
hl7:code
|
CE |
0 … 1 |
|
|
(gebion) |
| |
CONF |
| moet uit concept domein "RoleCode" worden gekozen |
|
hl7:addr
|
AD |
0 … 1 |
|
|
(gebion) |
hl7:telecom
|
TEL |
0 … * |
|
|
(gebion) |
hl7:assignedPerson
|
|
0 … 1 |
|
|
(gebion) |
| Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.11.60.66.10.9001 PART CDA Person (DYNAMISCH)
|
@classCode
|
|
0 … 1 |
F |
PSN |
@determinerCode
|
|
0 … 1 |
F |
INSTANCE |
hl7:name
|
PN |
0 … * |
|
|
(gebion) |
| |
|
hl7:representedOrganization
|
|
0 … 1 |
|
|
(gebion) |
| Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.11.60.66.10.9002 PART CDA Organization (DYNAMISCH)
|
@classCode
|
|
0 … 1 |
F |
ORG |
@determinerCode
|
|
0 … 1 |
F |
INSTANCE |
hl7:id
|
II.NL.URA |
1 … 1 |
R |
URA |
(gebion) |
| |
|
@root
|
|
1 … 1 |
F |
2.16.528.1.1007.3.3 |
hl7:id
|
II |
0 … * |
|
Andere IDs |
(gebion) |
| |
|
hl7:name
|
ON |
1 … 1 |
R |
|
(gebion) |
| |
|
hl7:telecom
|
TEL |
0 … * |
|
|
(gebion) |
| |
|
hl7:addr
|
AD |
0 … 1 |
|
|
(gebion) |
| |
|
hl7:standardIndustryClassCode
|
CE |
0 … 1 |
|
|
(gebion) |
| |
|
| |
CONF |
|
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. |
(gebion) |
| Inclusie |
|
|
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 |
|
|
(gebion) |
| |
CONF |
| moet uit concept domein "Participation Function" worden gekozen |
|
hl7:time
|
TS |
1 … 1 |
R |
|
(gebion) |
hl7:assignedAuthor
|
|
1 … 1 |
R |
|
(gebion) |
@classCode
|
|
0 … 1 |
F |
ASSIGNED |
hl7:id
|
II |
1 … * |
R |
|
(gebion) |
hl7:code
|
CE |
0 … 1 |
|
|
(gebion) |
| |
CONF |
| moet uit concept domein "Role Code" worden gekozen |
|
hl7:addr
|
AD |
0 … * |
|
|
(gebion) |
hl7:telecom
|
TEL |
0 … * |
|
|
(gebion) |
| Keuze |
0 … 1 |
|
Elementen om uit te kiezen:
|
hl7:assignedPerson
|
|
0 … 1 |
|
Bevat 2.16.840.1.113883.2.4.3.11.60.66.10.9001 PART CDA Person (DYNAMISCH)
|
(gebion) |
hl7:assignedAuthoringDevice
|
|
0 … 1 |
|
Bevat 2.16.840.1.113883.2.4.3.11.60.66.10.9008 PART CDA Device (DYNAMISCH)
|
(gebion) |
hl7:representedOrganization
|
|
0 … 1 |
|
Bevat 2.16.840.1.113883.2.4.3.11.60.66.10.9002 PART CDA Organization (DYNAMISCH)
|
(gebion) |
 |
|
|
waar [hl7:id [@root = '2.16.528.1.1007.3.3']] |
|
|
| Keuze |
… 3 |
|
A Laboratory Observation MAY contain up to 3 types of participants "AUTHEN", "RESP",
and "DEV". Elementen om uit te kiezen:
- hl7:participant[@typeCode='AUTHEN']
- hl7:participant[@typeCode='RESP']
- hl7:participant[@typeCode='DEV']
|
hl7:participant
|
|
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. |
(gebion) |
|
|
waar [@typeCode='AUTHEN'] |
|
|
@typeCode
|
|
1 … 1 |
F |
AUTHEN |
| Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.11.60.66.10.9007 PART CDA Participant (Body) (DYNAMISCH)
|
@typeCode
|
cs |
1 … 1 |
R |
|
| |
CONF |
|
@contextControlCode
|
|
1 … 1 |
F |
OP |
hl7:time
|
IVL_TS |
0 … 1 |
|
|
(gebion) |
hl7:awarenessCode
|
CE |
0 … 1 |
|
|
(gebion) |
| |
CONF |
|
hl7:participantRole
|
|
1 … 1 |
R |
|
(gebion) |
@classCode
|
|
0 … 1 |
F |
ROL |
hl7:id
|
II |
0 … * |
|
|
(gebion) |
hl7:code
|
CE |
0 … 1 |
|
|
(gebion) |
| |
CONF |
| moet uit concept domein "RoleCode" worden gekozen |
|
hl7:addr
|
AD |
0 … * |
|
|
(gebion) |
hl7:telecom
|
TEL |
0 … * |
|
|
(gebion) |
| Keuze |
0 … * |
|
Elementen om uit te kiezen:
|
hl7:playingDevice
|
|
0 … * |
|
Bevat 2.16.840.1.113883.2.4.3.11.60.66.10.9008 PART CDA Device (DYNAMISCH)
|
(gebion) |
hl7:playingEntity
|
|
0 … * |
|
Bevat 2.16.840.1.113883.2.4.3.11.60.66.10.9009 PART CDA PlayingEntity (DYNAMISCH)
|
(gebion) |
hl7:scopingEntity
|
|
0 … 1 |
|
|
(gebion) |
@classCode
|
|
0 … 1 |
F |
ENT |
@determinerCode
|
|
0 … 1 |
F |
INSTANCE |
hl7:id
|
II |
0 … * |
|
|
(gebion) |
hl7:code
|
CE |
0 … 1 |
|
|
(gebion) |
| |
CONF |
|
hl7:desc
|
ED |
0 … 1 |
|
|
(gebion) |
hl7:participant
|
|
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. |
(gebion) |
|
|
waar [@typeCode='RESP'] |
|
|
@typeCode
|
|
1 … 1 |
F |
RESP |
| Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.11.60.66.10.9007 PART CDA Participant (Body) (DYNAMISCH)
|
@typeCode
|
cs |
1 … 1 |
R |
|
| |
CONF |
|
@contextControlCode
|
|
1 … 1 |
F |
OP |
hl7:time
|
IVL_TS |
0 … 1 |
|
|
(gebion) |
hl7:awarenessCode
|
CE |
0 … 1 |
|
|
(gebion) |
| |
CONF |
|
hl7:participantRole
|
|
1 … 1 |
R |
|
(gebion) |
@classCode
|
|
0 … 1 |
F |
ROL |
hl7:id
|
II |
0 … * |
|
|
(gebion) |
hl7:code
|
CE |
0 … 1 |
|
|
(gebion) |
| |
CONF |
| moet uit concept domein "RoleCode" worden gekozen |
|
hl7:addr
|
AD |
0 … * |
|
|
(gebion) |
hl7:telecom
|
TEL |
0 … * |
|
|
(gebion) |
| Keuze |
0 … * |
|
Elementen om uit te kiezen:
|
hl7:playingDevice
|
|
0 … * |
|
Bevat 2.16.840.1.113883.2.4.3.11.60.66.10.9008 PART CDA Device (DYNAMISCH)
|
(gebion) |
hl7:playingEntity
|
|
0 … * |
|
Bevat 2.16.840.1.113883.2.4.3.11.60.66.10.9009 PART CDA PlayingEntity (DYNAMISCH)
|
(gebion) |
hl7:scopingEntity
|
|
0 … 1 |
|
|
(gebion) |
@classCode
|
|
0 … 1 |
F |
ENT |
@determinerCode
|
|
0 … 1 |
F |
INSTANCE |
hl7:id
|
II |
0 … * |
|
|
(gebion) |
hl7:code
|
CE |
0 … 1 |
|
|
(gebion) |
| |
CONF |
|
hl7:desc
|
ED |
0 … 1 |
|
|
(gebion) |
hl7:participant
|
|
0 … 1 |
|
A device or equipment, which was used to produce this set of results (e.g. an analyzer). |
(gebion) |
|
|
waar [@typeCode='DEV'] |
|
|
@typeCode
|
|
1 … 1 |
F |
DEV |
| Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.11.60.66.10.9007 PART CDA Participant (Body) (DYNAMISCH)
|
@typeCode
|
cs |
1 … 1 |
R |
|
| |
CONF |
|
@contextControlCode
|
|
1 … 1 |
F |
OP |
hl7:time
|
IVL_TS |
0 … 1 |
|
|
(gebion) |
hl7:awarenessCode
|
CE |
0 … 1 |
|
|
(gebion) |
| |
CONF |
|
hl7:participantRole
|
|
1 … 1 |
R |
|
(gebion) |
@classCode
|
|
0 … 1 |
F |
ROL |
hl7:id
|
II |
0 … * |
|
|
(gebion) |
hl7:code
|
CE |
0 … 1 |
|
|
(gebion) |
| |
CONF |
| moet uit concept domein "RoleCode" worden gekozen |
|
hl7:addr
|
AD |
0 … * |
|
|
(gebion) |
hl7:telecom
|
TEL |
0 … * |
|
|
(gebion) |
| Keuze |
0 … * |
|
Elementen om uit te kiezen:
|
hl7:playingDevice
|
|
0 … * |
|
Bevat 2.16.840.1.113883.2.4.3.11.60.66.10.9008 PART CDA Device (DYNAMISCH)
|
(gebion) |
hl7:playingEntity
|
|
0 … * |
|
Bevat 2.16.840.1.113883.2.4.3.11.60.66.10.9009 PART CDA PlayingEntity (DYNAMISCH)
|
(gebion) |
hl7:scopingEntity
|
|
0 … 1 |
|
|
(gebion) |
@classCode
|
|
0 … 1 |
F |
ENT |
@determinerCode
|
|
0 … 1 |
F |
INSTANCE |
hl7:id
|
II |
0 … * |
|
|
(gebion) |
hl7:code
|
CE |
0 … 1 |
|
|
(gebion) |
| |
CONF |
|
hl7:desc
|
ED |
0 … 1 |
|
|
(gebion) |
hl7:entryRelationship
|
|
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.
Bevat 2.16.840.1.113883.2.4.3.11.60.2.10.6 GEBB Comment Activity (DYNAMISCH)
|
(gebion) |
|
waar [@typeCode='COMP'] |
|
|
@typeCode
|
|
1 … 1 |
F |
COMP |
hl7:entryRelationship
|
|
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.
Bevat 2.16.840.1.113883.2.4.3.11.60.2.10.5 GEBB Laboratory Observation (DYNAMISCH)
|
(gebion) |
|
waar [@typeCode='REFR'] |
|
|
@typeCode
|
|
1 … 1 |
F |
REFR |
| Inclusie |
0 … 1 |
|
van 2.16.840.1.113883.2.4.3.11.60.66.10.9005 PART CDA Observation Reference Range (DYNAMISCH)
|
hl7:referenceRange
|
|
0 … 1 |
|
Referentiewaarden |
(gebion) |
@typeCode
|
|
1 … 1 |
F |
REFV |
| |
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"/> <high nullFlavor="PINF"/> </value> <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" codeSystemName="ObservationInterpretation"/> </observationRange></referenceRange> |
hl7:observationRange
|
|
1 … 1 |
M |
|
(gebion) |
@classCode
|
|
1 … 1 |
F |
OBS |
@moodCode
|
|
1 … 1 |
F |
EVN.CRT |
hl7:code
|
|
|
NP |
|
(gebion) |
hl7:text
|
ED |
0 … 1 |
|
|
(gebion) |
hl7:value
|
IVL_PQ |
0 … 1 |
|
|
(gebion) |
hl7:low
|
PQ |
1 … 1 |
R |
|
(gebion) |
@value
|
|
0 … 1 |
|
Ondergrens waarde |
@unit
|
|
0 … 1 |
|
Ondergrens eenheid |
@nullFlavor
|
cs |
0 … 1 |
|
Alleen relevant indien ondergrens onbekend is. 'NI' voor een ondergrens waarvoor helemaal
geen informatie bekend is. 'UNK' voor situaties waarin je weet dat er een waarde is,
maar je deze niet hebt. In meer uitzonderlijke gevallen zijn 'NINF' en 'TRC' (Onmeetbaar
dicht tegen 0 aan) denkbaar.
|
| |
Schematron assert |
role |
 error
|
|
| |
test |
not(@nullFlavor='PINF') |
|
| |
Melding |
NullFlavor PINF is geen geldige ondergrens omdat deze altijd boven de bovengrens zou
liggen |
|
hl7:high
|
PQ |
1 … 1 |
R |
|
(gebion) |
@value
|
|
0 … 1 |
|
Bovengrens waarde |
@unit
|
|
0 … 1 |
|
Bovengrens eenheid |
@nullFlavor
|
cs |
0 … 1 |
|
Alleen relevant indien bovengrens onbekend is. 'NI' voor een bovengrens waarvoor helemaal
geen informatie bekend is. 'UNK' voor situaties waarin je weet dat er een waarde is,
maar je deze niet hebt. In meer uitzonderlijke gevallen zijn 'PINF' (Positive infinity)
en 'TRC' (Onmeetbaar dicht tegen 0 aan) denkbaar.
|
| |
Schematron assert |
role |
error
|
|
| |
test |
not(@nullFlavor='NINF') |
|
| |
Melding |
NullFlavor NINF is geen geldige bovengrens omdat deze altijd onder de ondergrens zou
liggen |
|
hl7:interpretationCode
|
CV |
1 … 1 |
M |
|
(gebion) |
@code
|
CONF |
1 … 1 |
F |
N |
@codeSystem
|
1 … 1 |
F |
2.16.840.1.113883.5.83 (Observation Interpretation) |
Template GEBB Laboratory Observation
Circulaire referentie gevonden met 2.16.840.1.113883.2.4.3.11.60.2.10.5. Gaarne controleren
PART CDA Author (Body)
Naamgegevens