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Template Laboratory Observation 2008‑08‑08

Id1.3.6.1.4.1.19376.1.3.1.6
ref
XDLAB-
Effective Date2008‑08‑08
Statusactive ActiveVersion Label2017
NameLaboratoryObservationDisplay NameLaboratory Observation
Description
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.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.1.6
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 4 transactions and 48 templates, Uses 6 templates
Used by as NameVersion
2.16.840.1.113883.2.6.60.6.4.2Transactiondraft en-US CDA Document Anatomic Pathology Structured Report 2015
de-DE CDA Dokument Strukturierter Pathologiebefund (2.0)		2015‑10‑23 10:32:36
1.3.6.1.4.1.19376.1.5.3.1.4.11Transactiondraft en-US IHE Immunization Content2017‑03‑30 09:28:26
2.16.840.1.113883.2.4.3.11.60.7.4.2.13.1Transactiondeprecated nl-NL Registratie
en-US Registration (4.0)		2017‑09‑04
2.16.840.1.113883.2.4.3.11.60.7.4.2.13.1Transactionfinal nl-NL Registratie
en-US Registration (4.1)		2017‑12‑31
1.2.40.0.34.6.0.11.3.61Includedraft EMS Organizer Labor (2020)2020‑02‑20 16:12:29
1.2.40.0.34.11.13.3.26Containmentdraft ELGA Results Organizer (0.1)2017‑09‑09 17:12:50
1.2.40.0.34.11.30020Containmentretired ELGA Spezimen-Act-Entry Allgemein2012‑01‑07
1.2.40.0.34.11.30020Containmentretired ELGA Spezimen-Act-Entry Allgemein2014‑03‑04
1.2.40.0.34.11.30020Containmentretired ELGA Spezimen-Act-Entry Allgemein2015‑04‑30
1.2.40.0.34.11.30020Containmentretired ELGA Spezimen-Act-Entry Allgemein2017‑02‑20
1.2.40.0.34.11.30020Containmentdraft ELGA Spezimen-Act-Entry Allgemein2017‑02‑22
1.2.40.0.34.11.30023Includeretired Befundgruppen (Laboratory Battery Organizer)-deprecated2012‑01‑07
1.2.40.0.34.11.30025Containmentretired Kultureller Keimnachweis (Laboratory Isolate Organzier)2012‑01‑07
1.2.40.0.34.11.30025Containmentdraft Kultureller Keimnachweis (Laboratory Isolate Organzier)2017‑02‑23
1.2.40.0.34.777.10.10.998Containmentcancelled Befundgruppen (Laboratory Battery Organizer)2020‑04‑15 19:35:19
1.3.6.1.4.1.19376.1.3.1Containmentactive Laboratory Report Data Processing Entry (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.1Containmentdraft BC Laboratory Report Data Processing Entry2016‑04‑05 01:31:43
1.3.6.1.4.1.19376.1.3.1.4Containmentactive Laboratory Battery Organizer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.1.4Containmentretired Befundgruppen (Laboratory Battery Organizer)2013‑09‑09
1.3.6.1.4.1.19376.1.3.1.4Containmentdraft BC Laboratory Battery Organizer2016‑04‑05 01:44:00
1.3.6.1.4.1.19376.1.3.1.4Containmentdraft Befundgruppen (Laboratory Battery Organizer)2017‑02‑23
1.3.6.1.4.1.19376.1.3.1.5Containmentactive Laboratory Isolate Organizer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.1.5Containmentdraft BC Laboratory Isolate Organizer2016‑09‑29 14:55:37
1.3.6.1.4.1.19376.1.3.1.6Containmentdraft BC Laboratory Observation2016‑04‑05 01:50:49
1.3.6.1.4.1.19376.1.3.3linkactive Sharing Laboratory Reports (XD-LAB) Content Module (2017)2016‑07‑05
1.3.6.1.4.1.19376.1.3.3.2.1linkactive Laboratory Specialty Section (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.3.2.2linkactive Laboratory Report Item Section (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.10.3.1linkdraft Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2linkactive IHE Immunization Content Specification (2016)2017‑03‑20 09:59:31
1.3.6.1.4.1.19376.1.8.1.1.1linkdraft Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.1linkdraft Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2linkdraft Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3linkdraft Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4linkdraft Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5linkdraft Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.3.6Containmentdraft Problem Organizer (2.0)2015‑08‑13 10:24:55
2.16.840.1.113883.2.4.3.11.60.7.10.1linkretired Laboratory Battery or Isolate2017‑10‑16 14:59:25
2.16.840.1.113883.2.4.3.11.60.7.10.1linkpending Laboratory Battery or Isolate2021‑08‑30
2.16.840.1.113883.2.4.3.11.60.7.10.4linkretired Laboratory Isolate Organizer (Specimen)2017‑10‑16
2.16.840.1.113883.2.4.3.11.60.7.10.4linkpending Laboratory Isolate Organizer (Specimen)2021‑08‑30 14:45:51
2.16.840.1.113883.2.4.3.11.60.7.10.4linkcancelled Laboratory Isolate Organizer (Specimen)2021‑10‑27 17:00:31
2.16.840.1.113883.2.4.3.11.60.25.10.51linkdraft Lab2Zorg - Sharing Laboratory Reports (XD-LAB) (2017)2018‑06‑05 14:37:04
2.16.840.1.113883.2.4.3.11.60.25.10.52linkcancelled Laboratory Specialty Section (2017)2018‑06‑05 14:38:48
2.16.840.1.113883.2.4.3.11.60.25.10.52linkactive Laboratory Specialty Section2021‑10‑27
2.16.840.1.113883.2.4.3.11.60.25.10.52linkdraft Laboratory Specialty Section2022‑12‑20 14:13:14
2.16.840.1.113883.2.4.3.11.60.25.10.53linkretired Laboratory Report Data Processing Entry (2017)2018‑06‑05 14:42:09
2.16.840.1.113883.2.4.3.11.60.25.10.53linkpending Laboratory Report Data Processing Entry (2017)2021‑10‑27
2.16.840.1.113883.2.4.3.11.60.25.10.54linkcancelled Laboratory Report Item Section (2017)2018‑06‑05 14:44:20
2.16.840.1.113883.2.4.3.11.60.25.10.54linkactive Laboratory Report Item Section (2017)2021‑10‑27
2.16.840.1.113883.3.1937.99.61.41.10.18Containmentdraft Befundgruppen (Laboratory Battery Organizer)-Sandbox-sm2019‑03‑26 18:07:27
2.16.840.1.113883.3.1937.99.61.41.10.22Containmentdraft Kultureller Keimnachweis (Laboratory Isolate Organzier)-Sandbox-sm2019‑03‑26 18:12:07
2.16.840.1.113883.3.1937.99.61.41.10.27Containmentdraft Laboratory Report Data Processing Entry_Sandbox-sm (2017)2019‑03‑27 16:09:06
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.1.2Containmentactive Specimen Collection (2017)DYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.2.1Containmentactive Non-Human Subject (2017)DYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.3.1Containmentactive Human Patient with Non-Human Subject (2017)DYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.7Containmentactive Laboratory Performer (2017)DYNAMIC
1.3.6.1.4.1.19376.1.3.10.9.17Containmentactive Author with Name, Addr, Telecom (2017)DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.2Containmentactive IHE Comment Entry (2014)DYNAMIC
RelationshipGeneralization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
Example
Example
<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>
Example
Example
<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>
ItemDTCardConfDescriptionLabel
hl7:observation
1 … 1MLabodotstion
@classCode
cs1 … 1FOBS
@moodCode
cs1 … 1FEVN
hl7:templateId
II1 … 1MLabodotstion
@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.1.6
hl7:id
II0 … 1en-US A Laboratory Observation identifier MAY be present.Labodotstion
hl7:code
CD1 … 1Ren-US Unique test code in an international standard (LOINC or SNOMED CT) or a national standard (e.g. JC10 in Japan)Labodotstion
hl7:statusCode
CS1 … 1Men-US ‘completed’ when the result is present.
‘aborted’ if the test could not be performed.		Labodotstion
 CONF
@code shall be "completed"
or
@code shall be "aborted"
hl7:effectiveTime
IVL_TS0 … 1Ren-US Physiologically relevant timeLabodotstion
hl7:value
ANY0 … 1Ren-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.Labodotstion
hl7:interpretationCode
CE0 … 1Ren-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		Labodotstion
hl7:methodCode
CE0 … 1Ren-US method used for this observation expressed with ObservationMethod vocabulary (CWE)Labodotstion
Choice0 … 1Elements to choose from:
hl7:subject
0 … 1en-US subject in case of a non-human subject
Contains 1.3.6.1.4.1.19376.1.3.3.1.2.1 Non-Human Subject (DYNAMIC)		Labodotstion
@typeCode
cs0 … 1FSBJ
hl7:subject
0 … 1en-US subject in case of a non-human subject
Contains 1.3.6.1.4.1.19376.1.3.3.1.3.1 Human Patient with Non-Human Subject (DYNAMIC)		Labodotstion
@typeCode
cs0 … 1FSBJ
hl7:performer
0 … *en-US performer participation. Performer to supersede those recorded at higher level.
Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC)		Labodotstion
@typeCode
cs0 … 1FPRF
hl7:author
0 … *Ren-US author participation used to supersede the authors of higher level.
Contains 1.3.6.1.4.1.19376.1.3.10.9.17 Author with Name, Addr, Telecom (DYNAMIC)		Labodotstion
@typeCode
cs0 … 1FAUT
hl7:participant
0 … 1en-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.
Labodotstion
where [@typeCode='AUTHEN']
@typeCode
cs1 … 1FAUTHEN
hl7:participant
0 … 1en-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.
Labodotstion
where [@typeCode='RESP']
@typeCode
cs1 … 1FRESP
hl7:participant
0 … 1en-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).
Labodotstion
where [@typeCode='DEV']
@typeCode
cs1 … 1FDEV
hl7:entryRelationship
0 … *Ren-US Comment on this Observation
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (DYNAMIC)		Labodotstion
hl7:entryRelationship
0 … *Ren-US Specimen Collection
Contains 1.3.6.1.4.1.19376.1.3.1.2 Specimen Collection (DYNAMIC)		Labodotstion
hl7:entryRelationship
0 … *Ren-US Previous observations obtained for the same patient, test, same method, same unit (1)Labodotstion
where [@typeCode='REFR']
@typeCode
cs1 … 1FREFR
hl7:observation
1 … 1RLabodotstion
@classCode
cs1 … 1FOBS
@moodCode
cs1 … 1FEVN
hl7:code
1 … 1RLabodotstion
hl7:statusCode
1 … 1RLabodotstion
@code
1 … 1Fcompleted
hl7:effectiveTime
1 … 1RLabodotstion
hl7:value
1 … 1RLabodotstion
hl7:referenceRange
0 … 1Ren-US Reference range for the current test resultLabodotstion
@typeCode
cs0 … 1FREFV
hl7:observationRange
1 … 1MLabodotstion
@classCode
cs0 … 1FOBS
@moodCode
cs0 … 1FEVN.CRT
hl7:value
0 … 1nl-NL interval (IVL) representationLabodotstion
hl7:interpretationCode
CE1 … 1RLabodotstion
@code
CONF0 … 1FN
@codeSystem
0 … 1F2.16.840.1.113883.5.83
lab:precondition
0 … *en-US Extension to CDA Clinical statementLabodotstion
@typeCode
cs1 … 1FPRCN
lab:criterion
1 … 1RLabodotstion
@classCode
cs1 … 1FCOND
@moodCode
cs1 … 1FEVN
lab:code
CE1 … 1Ren-US Code of the criterion (e.g. age, sex)Labodotstion
lab:value
1 … 1Rnl-NL Value of the criterionLabodotstion