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draft Template  IPS Laboratory Result Observation

Id 2.16.840.1.113883.10.22.4.13 Effective Date 2024‑08‑04 11:10:20
Status draft Draft Version Label STU2
Name IPSLaboratoryResultObservation Display Name IPS Laboratory Result Observation
Description
This template constrains the results of a clinical laboratory observation. The result observation includes a statusCode to allow recording the status of an observation. “Pending” results (e.g., a test has been run but results have not been reported yet) should be represented as “active” ActStatus.
Context Parent nodes of template element with id 2.16.840.1.113883.10.22.4.13
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 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
2.16.840.1.113883.10.22.4.22 Containment pending IPS Comment Activity (STU1) DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.22.4.13 IPS Laboratory 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)
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.13"/>  <id root="1.2.3.999" extension="--example only--"/>  <code codeSystem="2.16.840.1.113883.6.1" code="41995-2" displayName="Hemoglobin A1c [Mass/volume] in Blood">
    <statusCode code="completed"/>    <effectiveTime>
      <low value="20171113173215"/>    </effectiveTime>    <value xsi:type="PQ" value="4.8" unit="%"/>    <interpretationCode code="H" displayName="High" codeSystem="2.16.840.1.113883.5.83"/>    <author>
      <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->
    </author>    <referenceRange>
      <observationRange>
        <value xsi:type="IVL_PQ">
          <low value="1.5" unit="%"/>          <high value="4.5" unit="%"/>        </value>        <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>      </observationRange>    </referenceRange>    <entryRelationship typeCode="COMP">
      <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' (dynamic) -->
    </entryRelationship>  </code></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 2.16.840.1.113883.10.22.4.13
hl7:id
 		II 0 … * R (IPSdotsion)
hl7:code
 		CD.IPS 1 … 1 M (IPSdotsion)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.75 IPS Results Laboratory/Pathology 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)
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 (extensible) 0 … 1 R (IPSdotsion)
where [@xsi:type='CE.IPS']
  CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.74 IPS Results Coded Values Laboratory/Pathology (DYNAMIC)
  Example
Blood group A+ from SNOMED CT
<value xsi:type="CE" code="278149003" codeSystem="2.16.840.1.113883.6.96" displayName="Blood group A Rh(D) positive"/>
  Example
Germ susceptible to antimicrobial agent from HL7 vocabulary
<value xsi:type="CE" code="S" codeSystem="2.16.840.1.113883.11.78" displayName="susceptible"/>
hl7:value
 		PQ 0 … 1 R (IPSdotsion)
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)
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)
where [@xsi:type='ST']
  Example
Result free text (data type ST)
<value xsi:type="ST">slight macrocytosis, check on alcohol consumption</value>
hl7:value
 		TS 0 … 1 R (IPSdotsion)
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)
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)
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 … 1 R The referenceRange is constrained to represent the normal range for this observation and this patient. (IPSdotsion)
hl7:observationRange
 		1 … 1 M (IPSdotsion)
hl7:code
 		CD NP (IPSdotsion)
hl7:value
 		ANY 1 … 1 M (IPSdotsion)
hl7:interpretationCode
 		CE.IPS 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)
@typeCode
 		cs 1 … 1 F COMP