3.13.2.1.2 Result observation

CONF-407: A result observation (templateId 2.16.840.1.113883.10.20.1.31) SHALL be represented with Observation.
CONF-408: The value for “Observation / @moodCode” in a result observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC.
CONF-409: A result observation SHALL contain at least one Observation / id.
CONF-410: A result observation SHALL contain exactly one Observation / statusCode.
CONF-411: A result observation SHOULD contain exactly one Observation / effectiveTime, which represents the biologically relevant time (e.g. time the specimen was obtained from the patient).
CONF-412: A result observation SHALL contain exactly one Observation / code.
CONF-413: The value for “Observation / code” in a result observation SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (codeSystem 2.16.840.1.113883.6.12).
CONF-414: A result observation MAY contain exactly one Observation / methodCode if the method isn't inherent in Observation / code or if there is a need to further specialize the method in Observation / code.
CONF-415: Observation / methodCodeSHALL NOT conflict with the method inherent in Observation / code.
CONF-416: A result observation SHALL contain exactly one Observation / value.
CONF-417: Where Observation / value is a physical quantity, the unit of measure SHALL be expressed using a valid Unified Code for Units of Measure (UCUM) expression.
CONF-418: A result observation SHOULD contain exactly one Observation / interpretationCode, which can be used to provide a rough qualitative interpretation of the observation, such as “N” (normal), “L” (low), “S” (susceptible), etc. Interpretation is generally provided for numeric results where an interpretation range has been defined, or for antimicrobial susceptibility test interpretation.
CONF-419: A result observation SHOULD contain one or more Observation / referenceRange to show the normal range of values for the observation result.
CONF-420: A result observation SHALL NOT contain Observation / referenceRange / observationRange / code, as this attribute is not used by the HL7 Clinical Statement or Lab Committee models.
CONF-421: A result observation SHALL contain one or more sources of information, as defined in section 5.2 Source.

3.4.2 Clinical statement conformance

The template identifier for a problem act is 2.16.840.1.113883.10.20.1.27.
The template identifier for a problem observation is 2.16.840.1.113883.10.20.1.28.
The template identifier for a result organizer is 2.16.840.1.113883.10.20.1.32.
The template identifier for a result observation is 2.16.840.1.113883.10.20.1.31.

Functional Statuses can be expressed in 3 different forms. They can occur as a Problem (see section 3.5 Problems), a Result (see section 3.13 Results) or as text. Text can be employed if and only if the Functional Status is neither a Problem nor a Result. Functional Statuses expressed as Problems include relevant clinical conditions, diagnoses, symptoms and findings. Results are the interpretation or conclusion derived from a clinical assessment or test battery, such as the Instrumental Activities of Daily Living (IADL) scale or the Functional Status Index (FSI).

CONF-128: A problem observation or result observation in the functional status section SHALL contain exactly one observation / code.
CONF-129: The value for “Observation / code” in a problem observation or result observation in the functional status section MAY be selected from ValueSet 2.16.840.1.113883.1.11.20.6 FunctionalStatusTypeCode STATIC 20061017.
CONF-131: If the functional status was collected using a standardized assessment instrument, then the question within that instrument SHOULD be represented in the “Observation / code” of a result observation, with a value selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96).
CONF-132: If the functional status was collected using a standardized assessment instrument containing questions with enumerated values as answers, then the answer SHOULD be represented in the “Observation / value” of a result observation.
CONF-133: If Observation / value in a result observation in the functional status section is of data type CE or CD, then it SHOULD use the same code system used to code the question in Observation / code.
CONF-134: Observation / value in a result observation in the functional status section MAY be of datatype CE or CD and MAY contain one or more Observation / value / translation, to represent equivalent values from other code systems.
CONF-135: A problem observation or result observation in the functional status section MAY use codes from the International Classification of Functioning, Disability, and Health (ICF, http://www.who.int/classifications/icf/en/) (codeSystem 2.16.840.1.113883.6.254).
CONF-137: A result observation in the functional status section SHALL contain exactly one status of functional status observation.