Draft| Description |
This template represents the results of a laboratory, radiology, or other study performed on a patient. The result observation includes a statusCode to allow recording the status of an observation. “Pending” results (e.g., a test has been run but results have not been reported yet) should be represented as “active” ActStatus. |
| Used by 0 transactions and 0 templates, Uses 1 template | ||||||||
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Specialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
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ad1bbr-
Version: template 2.16.840.1.113883.10.20.22.2.79 (2013‑01‑31)
| Item | DT | Card | Conf | Description | Label | ||
|---|---|---|---|---|---|---|---|
| cda:observation | BCCD onV3 | ||||||
| @classCode | cs | 1 … 1 | F | OBS | CONF7130 | ||
| SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-7130). | |||||||
| @moodCode | cs | 1 … 1 | F | EVN | CONF7131 | ||
| SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1198-7131). | |||||||
| hl7:templateId | II | 1 … 1 | M | BCCDonV3 | |||
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.2.79 | |||
| cda:templateId | II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1198-7136) such that it | CONF7136 | ||
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.2.79 | CONF9138 | ||
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.2" (CONF:1198-9138). | |||||||
| @extension | st | 1 … 1 | F | 2015-08-01 | CONF2575 | ||
| SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32575). | |||||||
| cda:id | II | 1 … * | SHALL contain at least one [1..*] id (CONF:1198-7137). | CONF7137 | |||
| cda:code | CD | 1 … 1 | M | SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:1198-7133). | CONF7133 | ||
| @codeSystem | CONF | 1 … 1 | F | 2.16.840.1.113883.6.1 | |||
| cda:statusCode | CS | 1 … 1 | R | SHALL contain exactly one [1..1] statusCode (CONF:1198-7134). | CONF7134 | ||
| cda:effectiveTime | IVL_TS | 1 … 1 | SHALL contain exactly one [1..1] effectiveTime (CONF:1198-7140). | CONF7140 | |||
| cda:value | 1 … 1 | M | SHALL contain exactly one [1..1] value (CONF:1198-7143). A coded or physical quantity value *MAY* contain zero or more [0..*] translations, which can be used to represent the original results as output by the lab. | CONF7143 | |||
| Constraint | If Observation/value is a physical quantity (*xsi:type*=*"PQ"*), the unit of measure *SHALL* be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 *DYNAMIC* | ||||||
| Schematron assert | role |  error | |||||
| test | (.[@xsi:type='CD'][@codeSystem='2.16.840.1.113883.6.96']) or not(.[@xsi:type='CD']) | ||||||
| Message | If Observation/value is a CD (*xsi:type*=*"CD"*) the value SHOULD be SNOMED-CT | ||||||
| cda:interpretationCode | 0 … * | R | SHOULD contain zero or more [0..*] interpretationCode (CONF:1198-7147). | CONF7147 | |||
| @code | 1 … 1 | R | The interpretationCode, if present, SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Observation Interpretation (HL7) urn:oid:2.16.840.1.113883.1.11.78 STATIC (CONF:1198-32476). | CONF2476 | |||
| cda:methodCode | CE | 0 … 1 | MAY contain zero or one [0..1] methodCode (CONF:1198-7148). | CONF7148 | |||
| cda:targetSiteCode | CD | 0 … 1 | MAY contain zero or one [0..1] targetSiteCode (CONF:1198-7153). | CONF7153 | |||
| cda:author | 0 … * | R | SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1198-7149). Contains
| CONF7149 | |||
| cda:referenceRange | 0 … * | R | SHOULD contain zero or more [0..*] referenceRange (CONF:1198-7150). | CONF7150 | |||
| cda:observationRange | 1 … 1 | M | The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:1198-7151). | CONF7151 | |||
| cda:code | CD | NP | This observationRange SHALL NOT contain [0..0] code (CONF:1198-7152). | CONF7152 | |||
| cda:value | 1 … 1 | R | This observationRange SHALL contain exactly one [1..1] value (CONF:1198-32175). | CONF2175 | |||
