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draft Template  IPS Radiology Result Observation

Id 2.16.840.1.113883.10.22.4.12 Effective Date 2024‑08‑04 20:18:00
Status draft Draft Version Label STU2
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 3 templates
Used by as Name Version
2.16.840.1.113883.10.22.4.9 Containment pending IPS Result Organizer (STU1) 2017‑03‑02
2.16.840.1.113883.10.22.3.14 link pending IPS Results Section (STU1) 2017‑04‑30
2.16.840.1.113883.10.22.1.1 link draft International Patient Summary (2021) 2020‑07‑14 16:08:21
Uses as Name Version
2.16.840.1.113883.10.22.4.14 Include pending IPS Body Author (STU1) DYNAMIC
2.16.840.1.113883.10.22.17 Containment draft IPS Radiology Result Observation Component (STU2) DYNAMIC
2.16.840.1.113883.10.22.4.22 Containment pending IPS Comment Activity (STU1) DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.22.4.12 IPS Radiology Result Observation (2017‑03‑21)
Adaptation: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.22.4.2 Result Observation (V3) (2015‑08‑01)
ref
ccda-

Adaptation: template 2.16.840.1.113883.10.22.4.10 IPS Result Observation (2017‑03‑02)
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 Radiology Observation (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)
hl7:value
 		ST 0 … 1 R Actual result, free text (data type ST) (IPSdotsion)
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 Body 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-CT)
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-CT)
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)
Included 0 … * R from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
hl7:author
 		0 … * R (IPSdotsion)
hl7:templateId
 		II 1 … 1 M (IPSdotsion)
@root
 		uid 1 … 1 F 2.16.840.1.113883.10.22.4.14
hl7:time
 		TS.IPS.TZ 1 … 1 R (IPSdotsion)
hl7:assignedAuthor
 		1 … 1 M (IPSdotsion)
hl7:id
 		II 1 … * R (IPSdotsion)
hl7:code
 		0 … 1 R (IPSdotsion)
Choice 0 … 1 Elements to choose from:
  • hl7:assignedPerson
  • hl7:assignedAuthoringDevice
hl7:assignedPerson
 		0 … 1 C (IPSdotsion)
@classCode
 		cs 0 … 1 F PSN
@determinerCode
 		cs 0 … 1 F INSTANCE
hl7:name
 		PN 1 … * R Name of the person (e.g. the Healthcare Professional)  authoring this document (IPSdotsion)
  Example <name>
  <given>John</given>  <family>Español Smith</family></name>
hl7:family
 		1 … * R (IPSdotsion)
hl7:given
 		1 … * R (IPSdotsion)
hl7:assignedAuthoringDevice
 		0 … 1 C (IPSdotsion)
  Example <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
@classCode
 		cs 0 … 1 F DEV
@determinerCode
 		cs 0 … 1 F INSTANCE
hl7:code
 		CE 0 … 1 (IPSdotsion)
hl7:manufacturerModelName
 		SC 0 … 1 (IPSdotsion)
hl7:softwareName
 		SC 0 … 1 (IPSdotsion)
hl7:representedOrganization
 		0 … 1 (IPSdotsion)
hl7:id
 		II 0 … * (IPSdotsion)
hl7:name
 		0 … * (IPSdotsion)
hl7:telecom
 		TEL 0 … * (IPSdotsion)
hl7:addr
 		AD 0 … * (IPSdotsion)
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 2.16.840.1.113883.10.22.17 IPS Radiology Result Observation Component (DYNAMIC) (IPSdotsion)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * Contains 2.16.840.1.113883.10.22.4.22 IPS Comment Activity (DYNAMIC) (IPSdotsion)
@typeCode
 		cs 1 … 1 F COMP