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Template BC Laboratory Observation 2016‑04‑05 01:50:49

Id1.3.6.1.4.1.19376.1.3.1.6Effective Date2016‑04‑05 01:50:49
Statusdraft DraftVersion Label
NameBCLaboratoryObservationDisplay NameBC Laboratory Observation
Description
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.

See also IHE PCC Wiki Content
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 0 transactions and 23 templates, Uses 2 templates
Used by as NameVersion
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
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
1.3.6.1.4.1.19376.1.3.1.6Containmentdraft BC Laboratory ObservationDYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.2Containmentactive IHE Comment Entry (2014)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-

Specialization: template 1.3.6.1.4.1.19376.1.3.1.6 Laboratory Observation (2008‑08‑08)
ref
XDLAB-
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 … 1MBCLadotstion
@classCode
cs1 … 1FOBS
@moodCode
cs1 … 1FEVN
hl7:templateId
II1 … 1MBCLadotstion
@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.1.6
hl7:id
II0 … 1A Laboratory Observation identifier MAY be present.BCLadotstion
hl7:code
CE1 … 1MA Laboratory Observation SHALL contain a unique test code from an international standard, such as LOINC.BCLadotstion
hl7:statusCode
CS1 … 1A 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.
BCLadotstion
 CONF
@code shall be "completed"
or
@code shall be "aborted"
hl7:effectiveTime
TS0 … 1RA Laboratory Observation MAY contain a relevant clinical time (ideally specimen collection time).BCLadotstion
hl7:value
ANY0 … 1RA 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.BCLadotstion
hl7:interpretationCode
CE0 … 1A 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. BCLadotstion
hl7:methodCode
CE0 … 1A 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.BCLadotstion
hl7:subject
0 … 1Subject in case of a non-human subject attached to the ObservationBCLadotstion
@typeCode
cs1 … 1FSBJ
hl7:specimen
0 … 1A Laboratory Observation MAY contain specimen documentation when it is different from the one documented at a higher level.BCLadotstion
@typeCode
cs1 … 1FSPC
hl7:specimenRole
0 … 1BCLadotstion
@classCode
cs1 … 1FSPEC
 Example<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>
hl7:id
II0 … 1specimen identifier known to the laboratoryBCLadotstion
hl7:specimenPlayingEntity
1 … 1BCLadotstion
 Example<specimenPlayingEntity>
  <code code="BLDV" codeSystem="2.16.840.1.113883.XXX.YYY" displayName="blood venous"/></specimenPlayingEntity>
hl7:code
CE1 … 1MThe specimen type coded with HL7 vocabulary SpecimenEntityType or another standard vocabularyBCLadotstion
 CONF
shall be drawn from concept domain "Specimen Entity Type"
lab:productOf
0 … 1Extension to CDA Clinical StatementBCLadotstion
@typeCode
cs1 … 1FPRD
 Example<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>
lab:procedure
BCLadotstion
@classCode
cs1 … 1FPROC
@moodCode
cs1 … 1FEVN
lab:code
CE0 … 1BCLadotstion
lab:effectiveTime
IVL_TS1 … 1MBCLadotstion
lab:targetSiteCode
CD0 … *BCLadotstion
hl7:performer
0 … 1A 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.BCLadotstion
@typeCode
cs1 … 1FPRF
hl7:author
0 … *RA 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.BCLadotstion
@typeCode
cs1 … 1FAUT
Choice … 3
A Laboratory Observation MAY contain up to 3 types of participants "AUTHEN", "RESP", and "DEV".
Elements to choose from:
  • hl7:participant[@typeCode='AUTHEN']
  • hl7:participant[@typeCode='RESP']
  • hl7:participant[@typeCode='DEV']
hl7:participant
0 … 1The 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.BCLadotstion
where [@typeCode='AUTHEN']
@typeCode
cs1 … 1FAUTHEN
hl7:participant
0 … 1The 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.BCLadotstion
where [@typeCode='RESP']
@typeCode
cs1 … 1FRESP
hl7:participant
0 … 1A device or equipment, which was used to produce this set of results (e.g. an analyzer).BCLadotstion
where [@typeCode='DEV']
@typeCode
cs1 … 1FDEV
hl7:entryRelationship
0 … *RA Laboratory Observation MAY contain test comments that shall be recorded using the Annotation Comment template within the Laboratory Observation as shown above.
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (DYNAMIC)		BCLadotstion
where [@typeCode='COMP']
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RA 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.
Contains 1.3.6.1.4.1.19376.1.3.1.6 BC Laboratory Observation (DYNAMIC)		BCLadotstion
where [@typeCode='REFR']
@typeCode
cs1 … 1FREFR
hl7:referenceRange
0 … 1RA 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.BCLadotstion
@typeCode
cs1 … 1FREFV
hl7:observationRange
1 … 1MBCLadotstion
@classCode
cs1 … 1FOBS
@moodCode
cs1 … 1FEVN.CRT
hl7:value
0 … 1nl-NL interval (IVL) representationBCLadotstion
hl7:interpretationCode
CV1 … 1RBCLadotstion
@code
CONF0 … 1FN
@codeSystem
0 … 1F2.16.840.1.113883.5.83
lab:precondition
0 … *Extension to CDA Clinical statementBCLadotstion
@typeCode
cs1 … 1FPRCN
lab:criterion
1 … 1BCLadotstion
@classCode
cs1 … 1FCOND
@moodCode
cs1 … 1FEVN
lab:code
CE1 … 1RCode of the criterion (e.g. age, sex)BCLadotstion
lab:value
1 … 1Rnl-NL Value of the criterionBCLadotstion