1.3.6.1.4.1.19376.1.3.1.6

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Template LaboratoryObservation

Actual version

Id	1.3.6.1.4.1.19376.1.3.1.6 ref (from repository: XDLAB-)	Effective Date	valid from 2008‑08‑08
Status	Active	Version Label	2017
Name	LaboratoryObservation	Display Name	Laboratory Observation
Description 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.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.1.6
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 8 templates, Uses 6 templates Used by as Name Version 1.3.6.1.4.1.19376.1.8.1.3.6 Containment Problem Organizer (2.0) 2015‑08‑13 10:24:55 1.3.6.1.4.1.19376.1.3.10.3.1 Additional Specified Observation Section (2.0) 2016‑11‑13 14:28:08 1.3.6.1.4.1.19376.1.8.1.1.1 Anatomic Pathology Structured Report Content Module (2.0) 2014‑05‑13 11:57:57 1.3.6.1.4.1.19376.1.8.1.2.1 Clinical Information Section (2.0) 2014‑05‑13 14:38:08 1.3.6.1.4.1.19376.1.8.1.2.2 Intraoperative Observation Section (2.0) 2014‑05‑13 19:29:16 1.3.6.1.4.1.19376.1.8.1.2.3 Macroscopic Observation Section (2.0) 2014‑05‑13 11:57:09 1.3.6.1.4.1.19376.1.8.1.2.4 Microscopic Observation Section (2.0) 2014‑05‑13 14:25:17 1.3.6.1.4.1.19376.1.8.1.2.5 Diagnostic Conclusion Section (2.0) 2014‑05‑13 19:31:26 Uses as Name Version 1.3.6.1.4.1.19376.1.3.3.1.2.1 Containment Non-Human Subject (2017) DYNAMIC 1.3.6.1.4.1.19376.1.3.3.1.3.1 Containment Human Patient with Non-Human Subject (2017) DYNAMIC 1.3.6.1.4.1.19376.1.3.3.1.7 Containment Laboratory Performer (2017) DYNAMIC 1.3.6.1.4.1.19376.1.3.10.9.17 Containment Author with Name, Addr, Telecom (2017) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.4.2 Containment IHE Comment Entry (2014) DYNAMIC 1.3.6.1.4.1.19376.1.3.1.2 Containment Specimen Collection (2017) DYNAMIC
Relationship	Generalization: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Example	Example <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>
Example	Example <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 Card Conf Description Label hl7:observation 1 … 1 M (Lab...ion) @classCode cs 1 … 1 F OBS @moodCode cs 1 … 1 F EVN hl7:templateId II 1 … 1 M (Lab...ion) @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. (Lab...ion) 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) (Lab...ion) hl7:statusCode CS 1 … 1 M ‘completed’ when the result is present. ‘aborted’ if the test could not be performed. (Lab...ion)   CONF @code shall be "completed" or @code shall be "aborted" hl7:effectiveTime IVL_TS 0 … 1 R Physiologically relevant time (Lab...ion) 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. (Lab...ion) 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 (Lab...ion) hl7:methodCode CE 0 … 1 R method used for this observation expressed with ObservationMethod vocabulary (CWE) (Lab...ion) Choice 0 … 1 Elements to choose from: hl7:subject containing template 1.3.6.1.4.1.19376.1.3.3.1.2.1 Non-Human Subject (DYNAMIC) hl7:subject containing template 1.3.6.1.4.1.19376.1.3.3.1.3.1 Human Patient with Non-Human Subject (DYNAMIC) hl7:subject 0 … 1 subject in case of a non-human subject Contains 1.3.6.1.4.1.19376.1.3.3.1.2.1 Non-Human Subject (DYNAMIC) (Lab...ion) where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.2.1']] @typeCode cs 0 … 1 F SBJ hl7:subject 0 … 1 subject in case of a non-human subject Contains 1.3.6.1.4.1.19376.1.3.3.1.3.1 Human Patient with Non-Human Subject (DYNAMIC) (Lab...ion) where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.3.1']] @typeCode cs 0 … 1 F SBJ 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) (Lab...ion) where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']] @typeCode cs 0 … 1 F PRF hl7:author 0 … * R author participation used to supersede the authors of higher level. Contains 1.3.6.1.4.1.19376.1.3.10.9.17 Author with Name, Addr, Telecom (DYNAMIC) (Lab...ion) @typeCode cs 0 … 1 F AUT hl7:participant 0 … 1 Other participants "AUTHEN", "RESP", and "DEV". AUTHEN: The verifier of the battery organizer. In the case where a laboratory report has multiple verifiers. Each verifier is attached to the subset of batteries/observations he or she verified, by the means of a <participant> element. (Lab...ion) where [@typeCode='AUTHEN'] @typeCode cs 1 … 1 F AUTHEN hl7:participant 0 … 1 Other participants "AUTHEN", "RESP", and "DEV". RESP: The person responsible for the provision of the battery. In the case where this battery is subcontracted to an external laboratory, this external laboratory (with its address and telcom) and the actual performer is represented by a <performer> element, whereas the Director of this subcontractor laboratory is carried by the <participant> element being attached to the same level as the <performer> element. (Lab...ion) where [@typeCode='RESP'] @typeCode cs 1 … 1 F RESP hl7:participant 0 … 1 Other participants "AUTHEN", "RESP", and "DEV". DEV: A device or equipment, which was used to produce this battery of results (e.g. an analyzer). (Lab...ion) where [@typeCode='DEV'] @typeCode cs 1 … 1 F DEV hl7:entryRelationship 0 … * R Comment on this Observation Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (DYNAMIC) (Lab...ion) where [hl7:act [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.20.1.40'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.2']]] hl7:entryRelationship 0 … * R Specimen Collection Contains 1.3.6.1.4.1.19376.1.3.1.2 Specimen Collection (DYNAMIC) (Lab...ion) where [hl7:procedure [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.1.2']]] hl7:entryRelationship 0 … * R Previous observations obtained for the same patient, test, same method, same unit (1) (Lab...ion) where [@typeCode='REFR'] @typeCode cs 1 … 1 F REFR hl7:observation 1 … 1 R (Lab...ion) @classCode cs 1 … 1 F OBS @moodCode cs 1 … 1 F EVN hl7:code 1 … 1 R (Lab...ion) hl7:statusCode 1 … 1 R (Lab...ion) @code 1 … 1 F completed hl7:effectiveTime 1 … 1 R (Lab...ion) hl7:value 1 … 1 R (Lab...ion) hl7:referenceRange 0 … 1 R Reference range for the current test result (Lab...ion) @typeCode cs 0 … 1 F REFV hl7:observationRange 1 … 1 M (Lab...ion) @classCode cs 0 … 1 F OBS @moodCode cs 0 … 1 F EVN.CRT hl7:value 0 … 1 interval (IVL) representation (Lab...ion) hl7:interpretationCode CE 1 … 1 R (Lab...ion) @code CONF 0 … 1 F N @codeSystem 0 … 1 F 2.16.840.1.113883.5.83 (Observation Interpretation) lab:precondition 0 … * Extension to CDA Clinical statement (Lab...ion) @typeCode cs 1 … 1 F PRCN lab:criterion 1 … 1 R (Lab...ion) @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) (Lab...ion) lab:value 1 … 1 R Value of the criterion (Lab...ion)

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• 2008-08-08 (Active)