| Item | DT | Card | Conf | Description | Label |
|---|
| | | | Observation with related previous results, reference range, participants, comments | (IHELaboratoryObservation) |
 | @classCode
|
| cs | 1 … 1 | F | OBS |
| @moodCode
|
| cs | 1 … 1 | F | EVN |
| hl7:templateId
|
| II | 1 … 1 | M | | (IHELaboratoryObservation) |
 | | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.3.1.6 |
| hl7:id
|
| II | 0 … 1 | | | (IHELaboratoryObservation) |
| hl7:code
|
| CD | 1 … 1 | M | Unique test code in an international standard (LOINC or SNOMED CT) or a national standard (e.g., JC10 in Japan) | (IHELaboratoryObservation) |
| hl7:statusCode
|
| CS | 1 … 1 | M | Values: - ‘completed’ when the result is present.
- ‘aborted’ if the test could not be performed.
| (IHELaboratoryObservation) |
| | CONF | | The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 ActStatusAbortedCompleted (DYNAMIC) |
|
| hl7:effectiveTime
|
| IVL_TS | 0 … 1 | | Physiologically relevant time | (IHELaboratoryObservation) |
| hl7:value
|
| ANY | 0 … 1 | | 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 ‘aborted’ observation. | (IHELaboratoryObservation) |
| hl7:interpretationCode
|
| CE | 0 … 1 | | 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
- SDD = Susceptible-dose dependent
This element may be coded with other values than those of the ObservationInterpretation vocabulary, given that the coding strength is CWE (coded with exceptions). | (IHELaboratoryObservation) |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 Observation Interpretation (HL7) (DYNAMIC) |
|
| hl7:methodCode
|
| CE | 0 … 1 | | method used for this observation expressed with ObservationMethod vocabulary (CWE) | (IHELaboratoryObservation) |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (DYNAMIC) |
|
| Choice | 0 … 1 | | Subject in case of a non-human subject attached to the Observation - hl7:subject containing template 1.3.6.1.4.1.19376.1.3.3.1.2.1 Non-Human Subject (Body) (DYNAMIC)
- hl7:subject containing template 1.3.6.1.4.1.19376.1.3.3.1.3.1 Human Patient with Non-Human Subject (Body) (DYNAMIC)
|
| | hl7:subject
|
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.3.3.1.2.1 Non-Human Subject (Body) (DYNAMIC) | (IHELaboratoryObservation) |
| | hl7:subject
|
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.3.3.1.3.1 Human Patient with Non-Human Subject (Body) (DYNAMIC) | (IHELaboratoryObservation) |
| 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) | (IHELaboratoryObservation) |
| hl7:author
|
| | 0 … * | | Author participation used to supersede the authors of higher level.
Contains 1.3.6.1.4.1.19376.1.3.1.9999.10.9.17 Author with Name, Addr, Telecom (DYNAMIC) | (IHELaboratoryObservation) |
| Choice | 0 … * | | Other participants such as verifier (AUTHEN) or responsible party (RESP). - hl7:participant
- hl7:participant containing template 1.3.6.1.4.1.19376.1.3.1.9999.10.9.10 CDA Participant (Body, responsible party) (DYNAMIC)
- hl7:participant containing template 1.3.6.1.4.1.19376.1.3.1.9999.10.9.11 CDA Participant (Body, device) (DYNAMIC)
|
| | hl7:participant
|
| | 0 … * | | AUTHEN for verifier, | (IHELaboratoryObservation) |
| | hl7:participant
|
| | 0 … * | | RESP for responsible party
Contains 1.3.6.1.4.1.19376.1.3.1.9999.10.9.10 CDA Participant (Body, responsible party) (DYNAMIC) | (IHELaboratoryObservation) |
| | hl7:participant
|
| | 0 … * | | DEV for device (e.g., lab analyzer)
Contains 1.3.6.1.4.1.19376.1.3.1.9999.10.9.11 CDA Participant (Body, device) (DYNAMIC) | (IHELaboratoryObservation) |
| hl7:entryRelationship
|
| | 0 … * | | Specimen on this Observation
Contains 1.3.6.1.4.1.19376.1.3.1.2 Specimen Collection (DYNAMIC) | (IHELaboratoryObservation) |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| hl7:entryRelationship
|
| | 0 … * | | Comment on this Observation
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (DYNAMIC) | (IHELaboratoryObservation) |
| | @typeCode
|
| cs | 1 … 1 | F | SUBJ |
| | A related statement is made about an act, or a cluster or battery of results. In CDA the former shall be recorded inside an <entryRelationship> element occurring at the end of the entry. |
| | @inversionInd
|
| bl | 1 … 1 | F | true |
| | The containing act is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'. |
| hl7:entryRelationship
|
| | 0 … * | | Contains 1.3.6.1.4.1.19376.1.3.1.9999.10.9.7 Previous observation (DYNAMIC) | (IHELaboratoryObservation) |
| | @typeCode
|
| cs | 1 … 1 | F | REFR |
| | Refers to a previous observation for the same test code on a previous specimen. |
| | hl7:sequenceNumber
|
| INT | 0 … 1 | | In case there is more than one previous result, the entryRelationship elements are sorted in reverse chronological order, and numbered from 1 to n by sequenceNumber. | (IHELaboratoryObservation) |
| int | 0 … 1 | | Contains the sequence number. |
| hl7:referenceRange
|
| | 0 … 1 | | | (IHELaboratoryObservation) |
| | @typeCode
|
| cs | 1 … 1 | F | REFV |
| | hl7:observationRange
|
| | 1 … 1 | M | | (IHELaboratoryObservation) |
| cs | 1 … 1 | F | OBS |
| cs | 1 … 1 | F | EVN.CRT |
| ANY | 0 … 1 | | interval (IVL) representation | (IHELaboratoryObservation) |
| CE | 1 … 1 | M | These are normal ranges | (IHELaboratoryObservation) |
| CONF | 1 … 1 | F | N |
| | 0 … * | | The Clinical Statement of CDA does not support the association of a criterion with a reference range, thus forbidding expressing in a Laboratory Report that a reference range is conditioned by the patient’s sex, and/or the patient’s age. The proposed extension to express these criteria is the same that has been adopted by the “Care Continuity Document” implementation guide: It adds a precondition actRelationship between ObservationRange class and Criterion class of the CDA entry model.
Contains 1.3.6.1.4.1.19376.1.3.1.9999.10.9.8 Observation Range Pre-Condition (DYNAMIC) | (IHELaboratoryObservation) |
Draft
