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draft Template  IPS Radiology Result Observation

Id 2.16.840.1.113883.10.22.4.12 Effective Date 2017‑03‑21
Status draft Draft Version Label
Name IPSRadiologyResultObservation Display Name IPS Radiology Result Observation
Description
This template represents an observation produced as one of the results of a radiology or other imaging study performed on a patient. 
In most cases, in the context of a patient summary this observation is final and validated, which is recorded with the value "completed" in the statusCode element. Should  the observation be not final, the statusCode would indicate "active", instead.
Context Parent nodes of template element with id 2.16.840.1.113883.10.22.4.12
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 3 templates, Uses 2 templates
Used by as Name Version
2.16.840.1.113883.10.22.4.9 Containment draft IPS Result Organizer 2017‑03‑02
2.16.840.1.113883.10.22.3.14 link draft IPS Results Section 2017‑04‑30
2.16.840.1.113883.10.22.1.1 link draft International Patient Summary 2017‑04‑11
Uses as Name Version
2.16.840.1.113883.10.22.4.14 Containment draft IPS Body Author DYNAMIC
2.16.840.1.113883.10.22.4.22 Containment draft IPS Comment Activity DYNAMIC
Relationship Adaptation: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Adaptation: template 2.16.840.1.113883.10.20.22.4.2 (2015‑08‑01)
Adaptation: template 2.16.840.1.113883.10.22.4.10 (2017‑03‑02)
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.12"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="..." codeSystem="1.2.3.999"/>  <statusCode code="active"/>  <effectiveTime>
    <low value="20170721091625"/>  </effectiveTime>  <!-- choice: 1..1
element hl7:value
element hl7:value
element hl7:value
-->
  <interpretationCode code="CAR" displayName="Carrier" codeSystem="2.16.840.1.113883.5.83"/>  <methodCode code="..." codeSystem="1.2.3.999"/>  <targetSiteCode>
    <qualifier>
      <name code="272741003" codeSystem="2.16.840.1.113883.6.96" displayName="Laterality"/>      <value code="..." codeSystem="2.16.840.1.113883.6.96"/>    </qualifier>    <qualifier>
      <name code="106233006" codeSystem="2.16.840.1.113883.6.96" displayName="Topographical modifier"/>      <value code="..." codeSystem="2.16.840.1.113883.6.96"/>    </qualifier>  </targetSiteCode>  <author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->
  </author>  <referenceRange>
    <observationRange>
      <value xsi:type="ANY"/>      <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" displayName="Normal"/>    </observationRange>  </referenceRange>  <entryRelationship typeCode="COMP">
    <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' (dynamic) -->
  </entryRelationship></observation>
Item DT Card Conf Description Label
hl7:observation
 (IPSdotsion)
@classCode
 cs 1 … 1 F OBS
@moodCode
 cs 1 … 1 F EVN
hl7:templateId
 II 1 … 1 M (IPSdotsion)
@root
 uid 1 … 1 F 2.16.840.1.113883.10.22.4.12
hl7:id
 II 0 … * R (IPSdotsion)
hl7:code
 CD.IPS (extensible) 1 … 1 M (IPSdotsion)
  CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.40 IPS Results Observation Radiology (DYNAMIC)
hl7:statusCode
 CS 1 … 1 M (IPSdotsion)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC)
hl7:effectiveTime
 IVL_TS 1 … 1 R (IPSdotsion)
Choice 1 … 1 Elements to choose from:
  • hl7:value[@xsi:type='CE.IPS']
  • hl7:value[@xsi:type='PQ']
  • hl7:value[@xsi:type='IVL_PQ']
  • hl7:value[@xsi:type='ST']
  • hl7:value[@xsi:type='TS']
  • hl7:value[@xsi:type='RTO_QTY_QTY']
hl7:value
 CE.IPS 0 … 1 R (IPSdotsion)
treeblank treeblank where [@xsi:type='CE.IPS']
  Example
Result code: code '201' from code system 2.16.840.1.113883.2.4.4.30.1045
<value xsi:type="CE" code="201" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="regular"/>
  Example
Result code: code 'POS' from code system 2.16.840.1.113883.5.83
<value xsi:type="CE" code="POS" codeSystem="2.16.840.1.113883.5.83"/>
hl7:value
 PQ 0 … 1 R (IPSdotsion)
treeblank treeblank where [@xsi:type='PQ']
  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
  Example
Result physical quantity (data type PQ): 136 mmol per liter
<value xsi:type="PQ" value="136" unit="mmol/L"/>
hl7:value
 IVL_PQ 0 … 1 R (IPSdotsion)
treeblank treeblank where [@xsi:type='IVL_PQ']
  Example
Result interval of physical quantities (data type IVL_PQ): 150 - 400 Billion per 10 exp 9 liter
<value xsi:type="IVL_PQ">
  <low value="150" unit="10+9/l"/>  <high value="400" unit="10+9/l"/></value>
hl7:value
 ST 0 … 1 R (IPSdotsion)
treeblank treeblank where [@xsi:type='ST']
  Example
Result free text (data type ST)
<value xsi:type="ST">This is a result as a free text</value>
hl7:value
 TS 0 … 1 R (IPSdotsion)
treeblank treeblank where [@xsi:type='TS']
  Example
Result time stamp (data type TS): 6-Aug-2014
<value xsi:type="TS" value="20140806"/>
hl7:value
 RTO_QTY_QTY 0 … 1 R (IPSdotsion)
treeblank treeblank where [@xsi:type='RTO_QTY_QTY']
  Example
Result ratio (data type RTO_QTY_QTY): 1/179
<value xsi:type="RTO_QTY_QTY">
  <numerator xsi:type="INT" value="1"/>  <denominator xsi:type="INT" value="179"/></value>
hl7:interpretationCode
 CE.IPS 0 … 1 R (IPSdotsion)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)
hl7:targetSiteCode
 CD.IPS (preferred) 0 … 1 (IPSdotsion)
  Constraint If the observation site is not precoordinated in the observation/code or observation/value it SHALL be specified in the observation/targetSiteCode
  CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.55 IPS Target Site (DYNAMIC)
hl7:qualifier
 CR 0 … 1 Laterality (IPSdotsion)
  Constraint The qualifier element for laterality SHALL be present if the targetSiteCode represents a paired body part and laterality is not pre-coordinated in the targetSiteCode
hl7:name
 CV (preferred) 1 … 1 M (IPSdotsion)
@code
 CONF 1 … 1 F 272741003
@codeSystem
 1 … 1 F 2.16.840.1.113883.6.96 (SNOMED Clinical Terms)
hl7:value
 CD.IPS (preferred) 1 … 1 M (IPSdotsion)
  CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.57 Laterality (qualifier) (DYNAMIC)
hl7:qualifier
 CR 0 … 1 Topographical modifier (IPSdotsion)
hl7:name
 CV (preferred) 1 … 1 M (IPSdotsion)
@code
 CONF 1 … 1 F 106233006
@codeSystem
 1 … 1 F 2.16.840.1.113883.6.96 (SNOMED Clinical Terms)
hl7:value
 CD.IPS (preferred) 1 … 1 M (IPSdotsion)
  CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.58 Topographical modifier (qualifier) (DYNAMIC)
hl7:author
 0 … * R Contains 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC) (IPSdotsion)
treeblank where [hl7:templateId [@root = '2.16.840.1.113883.10.22.4.14']]
hl7:referenceRange
 0 … * R (IPSdotsion)
hl7:observationRange
 1 … 1 M (IPSdotsion)
hl7:code
 CD NP (IPSdotsion)
hl7:value
 ANY 1 … 1 M (IPSdotsion)
hl7:interpretationCode
 CE 0 … 1 (IPSdotsion)
@code
 CONF 0 … 1 F N
@codeSystem
 0 … 1 F 2.16.840.1.113883.5.83 (Observation Interpretation)
hl7:entryRelationship
 0 … * Contains 2.16.840.1.113883.10.22.4.22 IPS Comment Activity (DYNAMIC) (IPSdotsion)
treeblank where [hl7:act [hl7:templateId [@root = '2.16.840.1.113883.10.22.4.22']]]
@typeCode
 cs 1 … 1 F COMP