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Template IPS Results Section 2017‑04‑30

Id2.16.840.1.113883.10.22.3.14Effective Date2017‑04‑30
Statuspending Under pre-publication reviewVersion LabelSTU1
NameIPSResultsSectionDisplay NameIPS Results Section
Description
This section assembles relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results may be laboratory results, others may be anatomic pathology results, others, radiology results, and others, clinical results.
The structured, machine-processable content of this section is sorted out between as many Result Organizer entries as needed. One Result Organizer entry groups results, which have a common context of production:
  • common specialty (imaging, bacteriology, serology, chemistry,  surgical pathology, clinical, radiology ...), 
  • common overall interpretation, (which interprets the set of results of the Organizer),
  • common biologic specimen for in vitro diagnostic observations, 
  • common associated illustrative image.
The optional author and informant elements of the section are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
In case this section assembles results from multiple authors (e.g.; results authored by a clinical laboratory, and results produced by a radiology center), the authors are listed in the section, and each Result Organizer of the section indicates its own author(s).
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.14
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
hl7ips-dataelement-19draft Results draft CEN/TC 251 prEN 17269
hl7ips-dataelement-126draft Observations results list draft CEN/TC 251 prEN 17269
hl7ips-dataelement-142draft Result Description draft CEN/TC 251 prEN 17269
Used by / Uses
Used by 1 transaction and 7 templates, Uses 4 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.777.13.4.2Transactiondraft IPS Created2017‑04‑07 11:10:54
2.16.840.1.113883.2.51.10.12Containmentactive XeH Hospital Discharge Report (1.0)2021‑09‑10 14:49:32
2.16.840.1.113883.2.51.10.13Containmentactive XeH RD Patient Summary (1.0)2021‑09‑10 14:50:49
2.16.840.1.113883.3.1937.99.61.67.10.8Containmentdraft XeH Hospital Discharge Report (0.1)2020‑10‑02 15:17:28
2.16.840.1.113883.3.1937.99.61.67.10.11Containmentdraft XeH RD Patient Summary (wip)2020‑10‑24 18:26:41
2.16.840.1.113883.10.22.1.1Containmentpending International Patient Summary (STU1)2017‑04‑11
2.16.840.1.113883.10.22.1.1Containmentpending International Patient Summary (TI-2020)2020‑05‑08 12:30:59
2.16.840.1.113883.10.22.1.1Containmentdraft International Patient Summary (2021)2020‑07‑14 16:08:21
Uses as NameVersion
2.16.840.1.113883.10.12.319Containmentactive CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.3.15Containmentdraft IPS Translation Section (2021)DYNAMIC
2.16.840.1.113883.10.22.4.9Containmentpending IPS Result Organizer (STU1)DYNAMIC
2.16.840.1.113883.10.22.4.14Containmentpending IPS Body Author (STU1)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
Example
Example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.3.14"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="30954-2" codeSystem="2.16.840.1.113883.6.1" displayName="Relevant diagnostic tests/laboratory data Narrative"/>  <title>MOST SIGNIFICANT RESULTS</title>  <text>
    <!-- some clinical laboratory results and some surgical pathology results presented to the human reader -->
  </text>
  <author>
    <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 1st author: a clinical lab director -->
  </author>
  <author>
    <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 2nd author: a pathologist -->
  </author>
  <entry typeCode="COMP" contextConductionInd="true">
    <!--- 1st Organizer: chemistry observations on blood serum specimen produced and interpreted by a clinical laboratory -->
    <organizer classCode="BATTERY" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.22.4.9"/>      <code code="18719-5" displayName="Chemistry studies (set)" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>      <satusCode code="completed"/>      <author>
        <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 1st author: a clinical lab director -->
      </author>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.30 'IPS Specimen Collection' - common blood serum specimen -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' - interpretation of chemistry results -->
      </component>
    </organizer>
  </entry>
  <entry>
    <organizer classCode="BATTERY" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.22.4.9"/>      <code code="18723-7" displayName="Hematology studies (set)" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>      <satusCode code="completed"/>      <author>
        <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 1st author: a clinical lab director -->
      </author>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.30 'IPS Specimen Collection' - venous blood total specimen -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' - interpretation of hematology results -->
      </component>
    </organizer>
  </entry>
  <entry>
    <organizer classCode="BATTERY" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.22.4.9"/>      <code code="11529-5" displayName="Surgical pathology studies (set)" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>      <satusCode code="completed"/>      <author>
        <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 2nd author: a pathologist -->
      </author>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.11 'IPS Pathology Result Observation' -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.30 'IPS Specimen Collection' - excised tissue specimen -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' - pathologist's interpretation -->
      </component>
      <component>
        <!-- template 2.16.840.1.113883.10.22.4.23 'IPS ObservationMedia' - an illustrative slide image -->
      </component>
    </organizer>
  </entry>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
IPSRdotstion
 
target
hl7ips-dataelement-19draft Results draft CEN/TC 251 prEN 17269
@classCode
cs0 … 1FDOCSECT
@moodCode
cs0 … 1FEVN
hl7:templateId
II1 … 1RIPSRdotstion
@root
uid1 … 1F2.16.840.1.113883.10.22.3.14
hl7:id
II0 … *RIPSRdotstion
hl7:code
CE.IPS1 … 1MIPSRdotstion
@code
CONF1 … 1F30954-2
@codeSystem
1 … 1F2.16.840.1.113883.6.1
hl7:title
ST1 … 1MIPSRdotstion
hl7:text
SD.TEXT1 … 1MIPSRdotstion
 
target
hl7ips-dataelement-142draft Result Description draft CEN/TC 251 prEN 17269
hl7:author
0 … *Contains 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)IPSRdotstion
hl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)IPSRdotstion
hl7:entry
1 … *MContains 2.16.840.1.113883.10.22.4.9 IPS Result Organizer (DYNAMIC)IPSRdotstion
 
target
hl7ips-dataelement-126draft Observations results list draft CEN/TC 251 prEN 17269
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
@contextConductionInd
bl0 … 1Ftrue
hl7:component
0 … *Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)IPSRdotstion