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draft Template  test Observation

Template 2.16.756.5.30.1.1.1.1.3.9.77.1.10.5 - testObservation
Id 2.16.756.5.30.1.1.1.1.3.9.77.1.10.5
Version gültig ab 2016‑03‑24 14:26:02 Status draft In Entwicklung
Klassifikation CDA Entry Level Template
Kontext Elternknoten des Template-Element mit Id 2.16.756.5.30.1.1.1.1.3.9.77.1.10.5
Offen/Geschlossen Offen (auch andere als die definierten Elemente sind erlaubt)
Beschreibung 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.
Benutzt von / Benutzt
Benutzt von 0 Templates, Benutzt 3 Templates
Benutzt Template-Id als Name Version
2.16.840.1.113883.3.1937.99.62.3.25.2 Inklusion testtextreference DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.2 Containment AnnotationComment DYNAMIC
1.3.6.1.4.1.19376.1.3.1.6 Containment LaboratoryObservation DYNAMIC
Beziehung Specialization: Template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Specialization: Template 1.3.6.1.4.1.19376.1.3.1.6 (2008‑08‑08)
Beispiel <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>
Beispiel <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 Kard Konf Beschreibung Label
hl7:observation
1 .. 1 M (testObservation)
treetree @classCode
cs 1 .. 1 F OBS
treetree @moodCode
cs 1 .. 1 F EVN
treetree hl7:templateId
II 1 .. 1 M (testObservation)
treeblank treetree @root
1 .. 1 F 2.16.756.5.30.1.1.1.1.3.9.77.1.10.5
treetree hl7:templateId
II 1 .. 1 M (testObservation)
treeblank treetree @root
uid 1 .. 1 F 1.3.6.1.4.1.19376.1.3.1.6
treetree hl7:id
II 0 .. 1 en-US A Laboratory Observation identifier MAY be present. (testObservation)
treetree hl7:code
CE 1 .. 1 M en-US A Laboratory Observation SHALL contain a unique test code from an international standard, such as LOINC. (testObservation)
Eingefügt von 2.16.840.1.113883.3.1937.99.62.3.25.2 test text reference (DYNAMIC) 0..*
treetree hl7:text
ED 0 .. * R Die Referenz auf den entsprechenden Text im menschlich lesbaren Teil muss mittels Referenz auf content[@ID] angegeben werden: reference[@value='#xxx'] (testObservation)
treeblank treetree hl7:reference
TEL 1 .. 1 M (testObservation)
treeblank treeblank treetree @value
1 .. 1 R
treetree hl7:statusCode
CS 1 .. 1 en-US 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.
 (testObservation)
  CONF
@code muss "completed" sein
oder
@code muss "aborted" sein
treetree hl7:effectiveTime
TS 0 .. 1 R en-US A Laboratory Observation MAY contain a relevant clinical time (ideally specimen collection time). (testObservation)
treetree hl7:value
ANY 0 .. 1 R en-US 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. (testObservation)
treetree hl7:interpretationCode
CE 0 .. 1 en-US 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. (testObservation)
treetree hl7:methodCode
CE 0 .. 1 en-US 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. (testObservation)
treetree hl7:subject
0 .. 1 en-US Subject in case of a non-human subject attached to the Observation (testObservation)
treeblank treetree @typeCode
cs 1 .. 1 F SBJ
treetree hl7:specimen
0 .. 1 en-US A Laboratory Observation MAY contain specimen documentation when it is different from the one documented at a higher level. (testObservation)
treeblank treetree @typeCode
cs 1 .. 1 F SPC
treeblank treetree hl7:specimenRole
0 .. 1 (testObservation)
treeblank treeblank treetree @classCode
cs 1 .. 1 F SPEC
  Beispiel <specimen typeCode="SPC">
  <specimenRole classCode="SPEC">
    <!-- Specimen unique ID assigned by the laboratory -->
    <id root="1.3.6.4.1.4.1.2835.1" extension="0321123456"/>
    <!-- Type of specimen : venous blood -->
    <specimenPlayingEntity>
      <!-- .. -->
    </specimenPlayingEntity>    <lab:productOf typeCode="PRD">
      <!-- .. -->
    </lab:productOf>  </specimenRole></specimen>
treeblank treeblank treetree hl7:id
II 0 .. 1 en-US specimen identifier known to the laboratory (testObservation)
treeblank treeblank treetree hl7:specimenPlayingEntity
1 .. 1 (testObservation)
  Beispiel <specimenPlayingEntity>
  <code code="BLDV" codeSystem="2.16.840.1.113883.XXX.YYY" displayName="blood venous"/>
</specimenPlayingEntity>
treeblank treeblank treeblank treetree hl7:code
CE 1 .. 1 M en-US The specimen type coded with HL7 vocabulary SpecimenEntityType or another standard vocabulary (testObservation)
  CONF
muss aus der Konzeptdomäne "Specimen Entity Type" gewählt werden
treeblank treeblank treetree lab:productOf
0 .. 1 en-US Extension to CDA Clinical Statement (testObservation)
treeblank treeblank treeblank treetree @typeCode
cs 1 .. 1 F PRD
  Beispiel <lab:productOf typeCode="PRD">
  <lab:procedure classCode="PROC" moodCode="EVN">
    <!-- Date time of specimen collection 6:30 a.m. on March 21 2006 -->
    <lab:effectiveTime value="200603210630"/>
  </lab:procedure></lab:productOf>
treeblank treeblank treeblank treetree lab:procedure
(testObservation)
treeblank treeblank treeblank treeblank treetree @classCode
cs 1 .. 1 F PROC
treeblank treeblank treeblank treeblank treetree @moodCode
cs 1 .. 1 F EVN
treeblank treeblank treeblank treeblank treetree lab:code
CE 0 .. 1 (testObservation)
treeblank treeblank treeblank treeblank treetree lab:effectiveTime
IVL_TS 1 .. 1 M (testObservation)
treeblank treeblank treeblank treeblank treetree lab:targetSiteCode
CD 0 .. * (testObservation)
treetree hl7:performer
0 .. 1 en-US 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. (testObservation)
treeblank treetree @typeCode
cs 1 .. 1 F PRF
treetree hl7:author
0 .. * R en-US 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. (testObservation)
treeblank treetree @typeCode
cs 1 .. 1 F AUT
Auswahl max 3 Element(e). Elemente in der Auswahl:
  • hl7:participant[@typeCode='AUTHEN']
  • hl7:participant[@typeCode='RESP']
  • hl7:participant[@typeCode='DEV']
treeblank treetree hl7:participant
wo
[@typeCode='AUTHEN']
0 .. 1 en-US 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. (testObservation)
treeblank treeblank treetree @typeCode
cs 1 .. 1 F AUTHEN
treeblank treetree hl7:participant
wo
[@typeCode='RESP']
0 .. 1 en-US 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. (testObservation)
treeblank treeblank treetree @typeCode
cs 1 .. 1 F RESP
treeblank treetree hl7:participant
wo
[@typeCode='DEV']
0 .. 1 en-US A device or equipment, which was used to produce this set of results (e.g. an analyzer). (testObservation)
treeblank treeblank treetree @typeCode
cs 1 .. 1 F DEV
treetree hl7:entryRelationship
wo
[@typeCode='COMP']
0 .. * R en-US A Laboratory Observation MAY contain test comments that shall be recorded using the Annotation Comment template within the Laboratory Observation as shown above. (testObservation)
treeblank treetree @typeCode
cs 1 .. 1 F COMP
  Beinhaltet 1.3.6.1.4.1.19376.1.5.3.1.4.2 Annotation Comment (DYNAMIC)
treetree hl7:entryRelationship
wo
[@typeCode='REFR']
0 .. * R en-US 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. (testObservation)
treeblank treetree @typeCode
cs 1 .. 1 F REFR
  Beinhaltet 1.3.6.1.4.1.19376.1.3.1.6 Laboratory Observation (DYNAMIC)
treetree hl7:referenceRange
0 .. 1 R en-US 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. (testObservation)
treeblank treetree @typeCode
cs 1 .. 1 F REFV
treeblank treetree hl7:observationRange
1 .. 1 M (testObservation)
treeblank treeblank treetree @classCode
cs 1 .. 1 F OBS
treeblank treeblank treetree @moodCode
cs 1 .. 1 F EVN.CRT
treeblank treeblank treetree hl7:value
0 .. 1 (testObservation)
treeblank treeblank treetree hl7:interpretationCode
CV 1 .. 1 R (testObservation)
treeblank treeblank treeblank treetree @code
1 .. 1 F N
treeblank treeblank treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.5.83 (Observation Interpretation)
treeblank treeblank treetree lab:precondition
0 .. * en-US Extension to CDA Clinical statement (testObservation)
treeblank treeblank treeblank treetree @typeCode
cs 1 .. 1 F PRCN
treeblank treeblank treeblank treetree lab:criterion
1 .. 1 (testObservation)
treeblank treeblank treeblank treeblank treetree @classCode
cs 1 .. 1 F COND
treeblank treeblank treeblank treeblank treetree @moodCode
cs 1 .. 1 F EVN
treeblank treeblank treeblank treeblank treetree lab:code
CE 1 .. 1 R en-US Code of the criterion (e.g. age, sex) (testObservation)
treeblank treeblank treeblank treeblank treetree lab:value
1 .. 1 R (testObservation)