1.3.6.1.4.1.19376.1.3.1.6/static-2016-07-05T000000

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Id1.3.6.1.4.1.19376.1.3.1.6
ref
(from repository: XDLAB-)
Effective Date valid from 2016‑07‑05

There are versions of templates with this id:
  • IHELaboratoryObservation as of 2016‑07‑05
  • LaboratoryObservation as of 2008‑08‑08
StatusKyellow.png DraftVersion Label2016
NameIHELaboratoryObservationDisplay NameLaboratory Observation
Description

The document SHALL contain at least one Laboratory Observation within each Laboratory Report Data Processing Entry.

ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.1.6
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 9 templates, Uses 10 templates
Used by Template id as NameVersion
1.3.6.1.4.1.19376.1.3.1.6ContainmentKorange.png Laboratory Observation (2008)2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.3.10.3.1Link.pngKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.1Link.pngKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2Link.pngKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3Link.pngKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4Link.pngKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5Link.pngKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
Uses Template id as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.2.1ContainmentKyellow.png Non-Human Subject (Body) (2016)DYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.3.1ContainmentKyellow.png Human Patient with Non-Human Subject (Body) (2016)DYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2008)DYNAMIC
1.3.6.1.4.1.19376.1.3.1.9999.10.9.17ContainmentKyellow.png Author with Name, Addr, Telecom (2016)DYNAMIC
1.3.6.1.4.1.19376.1.3.1.9999.10.9.10ContainmentKyellow.png CDA Participant (Body, responsible party) (2016)DYNAMIC
1.3.6.1.4.1.19376.1.3.1.9999.10.9.11ContainmentKyellow.png CDA Participant (Body, device) (2016)DYNAMIC
1.3.6.1.4.1.19376.1.3.1.2ContainmentKyellow.png Specimen Collection (2016)DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.2ContainmentKgreen.png IHE Comment Entry (2014)DYNAMIC
1.3.6.1.4.1.19376.1.3.1.9999.10.9.7ContainmentKyellow.png Previous observation (2016)DYNAMIC
1.3.6.1.4.1.19376.1.3.1.9999.10.9.8ContainmentKyellow.png Observation Range Pre-Condition (2016)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
ItemDTCardConfDescriptionLabel
hl7:observation

Observation with related previous results, reference range, participants, comments

(IHELaboratoryObservation)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IHELaboratoryObservation)
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.1.6
Treetree.pnghl7:id
II0 … 1(IHELaboratoryObservation)
Treetree.pnghl7:code
CD1 … 1M

Unique test code in an international standard (LOINC or SNOMED CT) or a national standard (e.g., JC10 in Japan)

(IHELaboratoryObservation)
Treetree.pnghl7:statusCode
CS1 … 1M

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)
Treetree.pnghl7:effectiveTime
IVL_TS0 … 1

Physiologically relevant time

(IHELaboratoryObservation)
Treetree.pnghl7:value
ANY0 … 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)
Treetree.pnghl7:interpretationCode
CE0 … 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)
Treetree.pnghl7:methodCode
CE0 … 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)
Choice0 … 1

Subject in case of a non-human subject attached to the Observation

Elements to choose from:
  • 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)
Treeblank.pngTreetree.pnghl7:subject
0 … 1Contains 1.3.6.1.4.1.19376.1.3.3.1.2.1 Non-Human Subject (Body) (DYNAMIC)(IHELaboratoryObservation)
Treeblank.pngTreetree.pnghl7:subject
0 … 1Contains 1.3.6.1.4.1.19376.1.3.3.1.3.1 Human Patient with Non-Human Subject (Body) (DYNAMIC)(IHELaboratoryObservation)
Treetree.pnghl7: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)
Treetree.pnghl7: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)
Choice0 … *

Other participants such as verifier (AUTHEN) or responsible party (RESP).

Elements to choose from:
  • 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)
Treeblank.pngTreetree.pnghl7:participant
0 … *

AUTHEN for verifier,

(IHELaboratoryObservation)
Treeblank.pngTreetree.pnghl7: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)
Treeblank.pngTreetree.pnghl7: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)
Treetree.pnghl7:entryRelationship
0 … *

Specimen on this Observation


Contains 1.3.6.1.4.1.19376.1.3.1.2 Specimen Collection (DYNAMIC)
(IHELaboratoryObservation)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7: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)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSUBJ
 

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.

Treeblank.pngTreetree.png@inversionInd
bl1 … 1Ftrue
 

The containing act is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'.

Treetree.pnghl7:entryRelationship
0 … *Contains 1.3.6.1.4.1.19376.1.3.1.9999.10.9.7 Previous observation (DYNAMIC)(IHELaboratoryObservation)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFR
 

Refers to a previous observation for the same test code on a previous specimen.

Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 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)
Treeblank.pngTreeblank.pngTreetree.png@value
int0 … 1 

Contains the sequence number.

Treetree.pnghl7:referenceRange
0 … 1(IHELaboratoryObservation)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFV
Treeblank.pngTreetree.pnghl7:observationRange
1 … 1M(IHELaboratoryObservation)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FOBS
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 … 1FEVN.CRT
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
ANY0 … 1

interval (IVL) representation

(IHELaboratoryObservation)
Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretationCode
CE1 … 1M

These are normal ranges

(IHELaboratoryObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF1 … 1FN
Treeblank.pngTreeblank.pngTreetree.pnghl7:precondition
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)