ref
XDLAB-
Aktiv| Beschreibung |
 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. |
| Benutzt von 1 Transaction und 8 Templates, Benutzt 6 Templates | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
CDA Dokument Strukturierter Pathologiebefund (2.0)
ref
ad1bbr-
| Beispiel |
| <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> |
| Beispiel |
| <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> |
| Item | DT | Kard | Konf | Beschreibung | Label | |||
|---|---|---|---|---|---|---|---|---|
| hl7:observation | 1 … 1 | M | Labo tion | |||||
| @classCode | cs | 1 … 1 | F | OBS | ||||
| @moodCode | cs | 1 … 1 | F | EVN | ||||
| hl7:templateId | II | 1 … 1 | M | Labotion | ||||
| @root | uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.3.1.6 | ||||
| hl7:id | II | 0 … 1 | A Laboratory Observation identifier MAY be present. | Labotion | ||||
| hl7:code | CD | 1 … 1 | R | Unique test code in an international standard (LOINC or SNOMED CT) or a national standard (e.g. JC10 in Japan) | Labotion | |||
| hl7:statusCode | CS | 1 … 1 | M | ‘completed’ when the result is present. ‘aborted’ if the test could not be performed. | Labotion | |||
| CONF |
| |||||||
| hl7:effectiveTime | IVL_TS | 0 … 1 | R | Physiologically relevant time | Labotion | |||
| hl7:value | ANY | 0 … 1 | R | The 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. | Labotion | |||
| hl7:interpretationCode | CE | 0 … 1 | R | One 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 | Labotion | |||
| hl7:methodCode | CE | 0 … 1 | R | method used for this observation expressed with ObservationMethod vocabulary (CWE) | Labotion | |||
| Auswahl | 0 … 1 | Elemente in der Auswahl:
| ||||||
| hl7:subject | 0 … 1 | subject in case of a non-human subject Beinhaltet 1.3.6.1.4.1.19376.1.3.3.1.2.1 Non-Human Subject (DYNAMIC) | Labotion | |||||
| @typeCode | cs | 0 … 1 | F | SBJ | ||||
| hl7:subject | 0 … 1 | subject in case of a non-human subject Beinhaltet 1.3.6.1.4.1.19376.1.3.3.1.3.1 Human Patient with Non-Human Subject (DYNAMIC) | Labotion | |||||
| @typeCode | cs | 0 … 1 | F | SBJ | ||||
| hl7:performer | 0 … * | performer participation. Performer to supersede those recorded at higher level. Beinhaltet 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC) | Labotion | |||||
| @typeCode | cs | 0 … 1 | F | PRF | ||||
| hl7:author | 0 … * | R | author participation used to supersede the authors of higher level. Beinhaltet 1.3.6.1.4.1.19376.1.3.10.9.17 Author with Name, Addr, Telecom (DYNAMIC) | Labotion | ||||
| @typeCode | cs | 0 … 1 | F | AUT | ||||
| hl7:participant | 0 … 1 | Other participants "AUTHEN", "RESP", and "DEV".
| Labotion | |||||
| wo [@typeCode='AUTHEN'] | ||||||||
| @typeCode | cs | 1 … 1 | F | AUTHEN | ||||
| hl7:participant | 0 … 1 | Other participants "AUTHEN", "RESP", and "DEV".
| Labotion | |||||
| wo [@typeCode='RESP'] | ||||||||
| @typeCode | cs | 1 … 1 | F | RESP | ||||
| hl7:participant | 0 … 1 | Other participants "AUTHEN", "RESP", and "DEV".
| Labotion | |||||
| wo [@typeCode='DEV'] | ||||||||
| @typeCode | cs | 1 … 1 | F | DEV | ||||
| hl7:entryRelationship | 0 … * | R | Comment on this Observation Beinhaltet 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (DYNAMIC) | Labotion | ||||
| hl7:entryRelationship | 0 … * | R | Specimen Collection Beinhaltet 1.3.6.1.4.1.19376.1.3.1.2 Specimen Collection (DYNAMIC) | Labotion | ||||
| hl7:entryRelationship | 0 … * | R | Previous observations obtained for the same patient, test, same method, same unit (1) | Labotion | ||||
| wo [@typeCode='REFR'] | ||||||||
| @typeCode | cs | 1 … 1 | F | REFR | ||||
| hl7:observation | 1 … 1 | R | Labotion | |||||
| @classCode | cs | 1 … 1 | F | OBS | ||||
| @moodCode | cs | 1 … 1 | F | EVN | ||||
| hl7:code | 1 … 1 | R | Labotion | |||||
| hl7:statusCode | 1 … 1 | R | Labotion | |||||
| @code | 1 … 1 | F | completed | |||||
| hl7:effectiveTime | 1 … 1 | R | Labotion | |||||
| hl7:value | 1 … 1 | R | Labotion | |||||
| hl7:referenceRange | 0 … 1 | R | Reference range for the current test result | Labotion | ||||
| @typeCode | cs | 0 … 1 | F | REFV | ||||
| hl7:observationRange | 1 … 1 | M | Labotion | |||||
| @classCode | cs | 0 … 1 | F | OBS | ||||
| @moodCode | cs | 0 … 1 | F | EVN.CRT | ||||
| hl7:value | 0 … 1 |  interval (IVL) representation | Labotion | |||||
| hl7:interpretationCode | CE | 1 … 1 | R | Labotion | ||||
| @code | CONF | 0 … 1 | F | N | ||||
| @codeSystem | 0 … 1 | F | 2.16.840.1.113883.5.83 | |||||
| lab:precondition | 0 … * | Extension to CDA Clinical statement | Labotion | |||||
| @typeCode | cs | 1 … 1 | F | PRCN | ||||
| lab:criterion | 1 … 1 | R | Labotion | |||||
| @classCode | cs | 1 … 1 | F | COND | ||||
| @moodCode | cs | 1 … 1 | F | EVN | ||||
| lab:code | CE | 1 … 1 | R | Code of the criterion (e.g. age, sex) | Labotion | |||
| lab:value | 1 … 1 | R | Value of the criterion | Labotion | ||||