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 7 transactions and 16 templates, Uses 1 template | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Transfer Summary (V2)
Health Concern Act (harmonized) (0.1)
ref
ad1bbr-
Version: template 2.16.840.1.113883.10.20.22.4.2 Result Observation (2013‑01‑31)
| Item | DT | Card | Conf | Description | Label |
|---|---|---|---|---|---|
| cda:observation | Resu 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). | |||||
| cda:templateId | II | 1 … 1 | M | C-CDA R1.1 templateId root without an extension | CONF2936 |
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.4.2 | |
| 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 | 2.16.840.1.113883.10.20.22.4.2 | 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 (extensible) | 1 … 1 | 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 | 0 … 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 | 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 DYNAMIC (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 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13) | 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 | |