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pending Template  IPS Results Section

Id 2.16.840.1.113883.10.22.3.14 Effective Date 2017‑04‑30
Status pending Under pre-publication review Version Label STU1
Name IPSResultsSection Display Name IPS Results Section
Description
This section assembles relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results may be laboratory results, others may be anatomic pathology results, others, radiology results, and others, clinical results.
The structured, machine-processable content of this section is sorted out between as many Result Organizer entries as needed. One Result Organizer entry groups results, which have a common context of production:
  • common specialty (imaging, bacteriology, serology, chemistry,  surgical pathology, clinical, radiology ...), 
  • common overall interpretation, (which interprets the set of results of the Organizer),
  • common biologic specimen for in vitro diagnostic observations, 
  • common associated illustrative image.
The optional author and informant elements of the section are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
In case this section assembles results from multiple authors (e.g.; results authored by a clinical laboratory, and results produced by a radiology center), the authors are listed in the section, and each Result Organizer of the section indicates its own author(s).
Context Parent nodes of template element with id 2.16.840.1.113883.10.22.3.14
Classification CDA Section Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 3 concepts
Id Name Data Set
hl7ips-dataelement-142 draft Result Description draft CEN/TC 251 prEN 17269
hl7ips-dataelement-126 draft Observations results list draft CEN/TC 251 prEN 17269
hl7ips-dataelement-19 draft Results draft CEN/TC 251 prEN 17269
Used by / Uses
Used by 1 transaction and 2 templates, Uses 4 templates
Used by as Name Version
hl7ips-transaction-2 Transaction draft IPS Created 2017‑04‑07 11:10:54
2.16.840.1.113883.10.22.1.1 Containment draft International Patient Summary 2020‑05‑08 12:30:59
2.16.840.1.113883.10.22.1.1 Containment pending International Patient Summary (STU1) 2017‑04‑11
Uses as Name Version
2.16.840.1.113883.10.22.4.14 Containment pending IPS Body Author (STU1) DYNAMIC
2.16.840.1.113883.10.12.319 Containment active CDA Informant (Body) DYNAMIC
2.16.840.1.113883.10.22.4.9 Containment pending IPS Result Organizer (STU1) DYNAMIC
2.16.840.1.113883.10.22.3.15 Containment pending IPS Translation Section (STU1) DYNAMIC
Relationship Adaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
Example
Example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.3.14"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="30954-2" codeSystem="2.16.840.1.113883.6.1" displayName="Relevant diagnostic tests/laboratory data Narrative"/>  <title>MOST SIGNIFICANT RESULTS</title>  <text>
    <!-- some clinical laboratory results and some surgical pathology results presented to the human reader -->
  </text>  <author>
    <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 1st author: a clinical lab director -->
  </author>  <author>
    <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 2nd author: a pathologist -->
  </author>  <entry typeCode="COMP" contextConductionInd="true">
    <!--- 1st Organizer: chemistry observations on blood serum specimen produced and interpreted by a clinical laboratory -->
    <organizer classCode="BATTERY" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.22.4.9"/>      <code code="18719-5" displayName="Chemistry studies (set)" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>      <satusCode code="completed"/>      <author>
        <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 1st author: a clinical lab director -->
      </author>      <component>
        <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->
      </component>      <component>
        <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->
      </component>      <component>
        <!-- template 2.16.840.1.113883.10.22.4.30 'IPS Specimen Collection' - common blood serum specimen -->
      </component>      <component>
        <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' - interpretation of chemistry results -->
      </component>    </organizer>  </entry>  <entry>
    <organizer classCode="BATTERY" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.22.4.9"/>      <code code="18723-7" displayName="Hematology studies (set)" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>      <satusCode code="completed"/>      <author>
        <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 1st author: a clinical lab director -->
      </author>      <component>
        <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->
      </component>      <component>
        <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->
      </component>      <component>
        <!-- template 2.16.840.1.113883.10.22.4.30 'IPS Specimen Collection' - venous blood total specimen -->
      </component>      <component>
        <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' - interpretation of hematology results -->
      </component>    </organizer>  </entry>  <entry>
    <organizer classCode="BATTERY" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.22.4.9"/>      <code code="11529-5" displayName="Surgical pathology studies (set)" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>      <satusCode code="completed"/>      <author>
        <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 2nd author: a pathologist -->
      </author>      <component>
        <!-- template 2.16.840.1.113883.10.22.4.11 'IPS Pathology Result Observation' -->
      </component>      <component>
        <!-- template 2.16.840.1.113883.10.22.4.30 'IPS Specimen Collection' - excised tissue specimen -->
      </component>      <component>
        <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' - pathologist's interpretation -->
      </component>      <component>
        <!-- template 2.16.840.1.113883.10.22.4.23 'IPS ObservationMedia' - an illustrative slide image -->
      </component>    </organizer>  </entry></section>
Item DT Card Conf Description Label
hl7:section
 		(IPSdotsion)
 
target
hl7ips-dataelement-19 draft Results draft CEN/TC 251 prEN 17269
@classCode
 		cs 0 … 1 F DOCSECT
@moodCode
 		cs 0 … 1 F EVN
hl7:templateId
 		II 1 … 1 R (IPSdotsion)
@root
 		uid 1 … 1 F 2.16.840.1.113883.10.22.3.14
hl7:id
 		II 0 … * R (IPSdotsion)
hl7:code
 		CE.IPS 1 … 1 M (IPSdotsion)
@code
 		CONF 1 … 1 F 30954-2
@codeSystem
 		1 … 1 F 2.16.840.1.113883.6.1 (LOINC)
hl7:title
 		ST 1 … 1 M (IPSdotsion)
hl7:text
 		SD.TEXT 1 … 1 M (IPSdotsion)
 
target
hl7ips-dataelement-142 draft Result Description draft CEN/TC 251 prEN 17269
hl7:author
 		0 … * Contains 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC) (IPSdotsion)
hl7:informant
 		0 … * Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC) (IPSdotsion)
hl7:entry
 		1 … * M Contains 2.16.840.1.113883.10.22.4.9 IPS Result Organizer (DYNAMIC) (IPSdotsion)
 
target
hl7ips-dataelement-126 draft Observations results list draft CEN/TC 251 prEN 17269
@typeCode
 		cs 1 … 1 R
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
@contextConductionInd
 		bl 0 … 1 F true
hl7:component
 		0 … * Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC) (IPSdotsion)