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Template Laboratory ObservationK 2019‑02‑19 17:10:40

Id2.16.840.1.113883.3.1937.99.61.41.10.8Effective Date2019‑02‑19 17:10:40
Statusdraft DraftVersion Label2017
NameLaboratoryObservation_KDisplay NameLaboratory ObservationK
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.
ContextParent nodes of template element with id 2.16.840.1.113883.3.1937.99.61.41.10.8
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 13 concepts
IdNameData Set
ssmith-dataelement-34draft Hämatokrit draft SMITH Sandbox
ssmith-dataelement-38draft Thrombozyten draft SMITH Sandbox
ssmith-dataelement-33draft Hämoglobin draft SMITH Sandbox
ssmith-dataelement-29draft Kreatinin draft SMITH Sandbox
ssmith-dataelement-254draft  draft SMITH Sandbox
ssmith-dataelement-264draft  draft SMITH Sandbox
ssmith-dataelement-261draft  draft SMITH Sandbox
ssmith-dataelement-260draft  draft SMITH Sandbox
ssmith-dataelement-259draft  draft SMITH Sandbox
ssmith-dataelement-258draft  draft SMITH Sandbox
ssmith-dataelement-257draft  draft SMITH Sandbox
ssmith-dataelement-256draft  draft SMITH Sandbox
ssmith-dataelement-255draft  draft SMITH Sandbox
Used by / Uses
Used by 0 transactions and 0 templates, Uses 6 templates
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 PerformerDYNAMIC
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
RelationshipAdaptation: template 1.3.6.1.4.1.19376.1.3.1.6 Laboratory Observation (2008‑08‑08)
ref
XDLAB-

Generalization: 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 … 1MLabodotson_K
 
target
ssmith-dataelement-254draft  draft SMITH Sandbox
@classCode
cs1 … 1FOBS
@moodCode
cs1 … 1FEVN
hl7:templateId
II1 … 1MLabodotson_K
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.41.10.8
hl7:id
II0 … 1A Laboratory Observation identifier MAY be present.Labodotson_K
 
target
ssmith-dataelement-255draft  draft SMITH Sandbox
hl7:code
CD1 … 1RUnique test code in an international standard (LOINC or SNOMED CT) or a national standard (e.g. JC10 in Japan)Labodotson_K
 
target
ssmith-dataelement-256draft  draft SMITH Sandbox
hl7:statusCode
CS1 … 1M‘completed’ when the result is present.
‘aborted’ if the test could not be performed.		Labodotson_K
 
target
ssmith-dataelement-29draft Kreatinin draft SMITH Sandbox
ssmith-dataelement-257draft  draft SMITH Sandbox
 CONF
@code shall be "completed"
or
@code shall be "aborted"
hl7:effectiveTime
IVL_TS0 … 1RPhysiologically relevant timeLabodotson_K
 
target
ssmith-dataelement-258draft  draft SMITH Sandbox
hl7:value
ANY0 … 1RThe 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.Labodotson_K
 
target
ssmith-dataelement-259draft  draft SMITH Sandbox
hl7:interpretationCode
CE0 … 1ROne 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		Labodotson_K
 
target
ssmith-dataelement-260draft  draft SMITH Sandbox
hl7:methodCode
CE0 … 1Rmethod used for this observation expressed with ObservationMethod vocabulary (CWE)Labodotson_K
 
target
ssmith-dataelement-261draft  draft SMITH Sandbox
Choice0 … 1Elements to choose from:
hl7:subject
0 … 1subject 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)		Labodotson_K
@typeCode
cs0 … 1FSBJ
hl7:subject
0 … 1subject 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)		Labodotson_K
@typeCode
cs0 … 1FSBJ
hl7:performer
0 … *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)		Labodotson_K
@typeCode
cs0 … 1FPRF
hl7:author
0 … *Rauthor 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)		Labodotson_K
@typeCode
cs0 … 1FAUT
hl7:participant
0 … 1Other 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.
Labodotson_K
where [@typeCode='AUTHEN']
@typeCode
cs1 … 1FAUTHEN
hl7:participant
0 … 1Other 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.
Labodotson_K
where [@typeCode='RESP']
@typeCode
cs1 … 1FRESP
hl7:participant
0 … 1Other participants "AUTHEN", "RESP", and "DEV".
  • DEV: A device or equipment, which was used to produce this battery of results (e.g. an analyzer).
Labodotson_K
where [@typeCode='DEV']
@typeCode
cs1 … 1FDEV
hl7:entryRelationship
0 … *RComment on this Observation
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (DYNAMIC)		Labodotson_K
hl7:entryRelationship
0 … *RSpecimen Collection
Contains 1.3.6.1.4.1.19376.1.3.1.2 Specimen Collection (DYNAMIC)		Labodotson_K
hl7:entryRelationship
0 … *RPrevious observations obtained for the same patient, test, same method, same unit (1)Labodotson_K
where [@typeCode='REFR']
@typeCode
cs1 … 1FREFR
hl7:observation
1 … 1RLabodotson_K
@classCode
cs1 … 1FOBS
@moodCode
cs1 … 1FEVN
hl7:code
1 … 1RLabodotson_K
hl7:statusCode
1 … 1RLabodotson_K
@code
1 … 1Fcompleted
hl7:effectiveTime
1 … 1RLabodotson_K
hl7:value
1 … 1RLabodotson_K
 
target
ssmith-dataelement-34draft Hämatokrit draft SMITH Sandbox
ssmith-dataelement-38draft Thrombozyten draft SMITH Sandbox
ssmith-dataelement-33draft Hämoglobin draft SMITH Sandbox
ssmith-dataelement-29draft Kreatinin draft SMITH Sandbox
hl7:referenceRange
0 … 1RReference range for the current test resultLabodotson_K
 
target
ssmith-dataelement-264draft  draft SMITH Sandbox
@typeCode
cs0 … 1FREFV
hl7:observationRange
1 … 1MLabodotson_K
@classCode
cs0 … 1FOBS
@moodCode
cs0 … 1FEVN.CRT
hl7:value
0 … 1nl-NL interval (IVL) representationLabodotson_K
hl7:interpretationCode
CE1 … 1RLabodotson_K
@code
CONF0 … 1FN
@codeSystem
0 … 1F2.16.840.1.113883.5.83
lab:precondition
0 … *Extension to CDA Clinical statementLabodotson_K
@typeCode
cs1 … 1FPRCN
lab:criterion
1 … 1RLabodotson_K
@classCode
cs1 … 1FCOND
@moodCode
cs1 … 1FEVN
lab:code
CE1 … 1RCode of the criterion (e.g. age, sex)Labodotson_K
lab:value
1 … 1Rnl-NL Value of the criterionLabodotson_K