1.3.6.1.4.1.19376.1.5.3.1.1.20.3.1

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Draft.gif Observation Request 1.3.6.1.4.1.19376.1.5.3.1.1.20.3.1

The observation request entry is used to record goals, plans or intention for an observation to be performed (e.g., assessment, laboratory test, imaging study, et cetera).


Uses

See Templates using Observation Request

Specification
Observation Request Example 
<observation classCode='OBS' moodCode='INT|PRP|GOL'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.20.3.1'/>
  <templateId root=''2.16.840.1.113883.10.20.1.25'/>
  <id root='' extension=''/>
  <code code='' displayName='' codeSystem='' codeSystemName=''/>
  <!-- for CDA -->
  <text><reference value='#xxx'/></text>
  <!-- For HL7 Version 3 Messages
  <text>text</text> 
  -->
  <statusCode code='active'/>
  <effectiveTime value=''/>
  <repeatNumber value=''/>
  <value xsi:type='' …/>
  <interpretationCode code='' codeSystem='' codeSystemName=''/>
  <methodCode code='' codeSystem='' codeSystemName=''/>
  <targetSiteCode code='' codeSystem='' codeSystemName=''/>
  <author typeCode='AUT'>
    <assignedAuthor typeCode='ASSIGNED'><id ... /></assignedAuthor> <!-- for CDA -->
    <!-- For HL7 Version 3 Messages 
    <assignedEntity typeCode='ASSIGNED'>
       <Person classCode='PSN'>
          <determinerCode root=''>
          <name>…</name>
       </Person>
    <assignedEntity>
     -->
  </author>
</observation>


<observation classCode='OBS' moodCode='INT|PRP|GOL'>

These acts are observations that form the care plan or which can be used in decision support. In intent mood (moodCode='INT') these are what is intended to be performed as part of the care plan. In proposal mood (moodCode='PRP'), these observations are being proposed, for example, as the output of a clinical decision support system. In goal mood (moodCode='GOL'), these observations described the intended goal of a treatment plan.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.20.3.1'/>

The <templateId> element identifies this <observation> as an observation request, allowing for validation of the content. The templateId must appear as shown above.

<templateId root=2.16.840.1.113883.10.20.1.25'/>

The IHE Observation Request template conforms to the Plan of care activity defined by the HL7 Continuity of Care Document. This template id must be present to indicate conformance.

<id root=' ' extension=' '/>

Each observation shall have an identifier.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

Observations shall have a code describing what is to be measured. The code system used is determined by the vocabulary constraints on the types of measurements that might be recorded in a section. Modules that are derived from the this one may restrict the code system and code values used for the observation.

<text><reference value='#xxx'/></text> -OR- <text>text</text>

Each observation request entry may contain a <text> element providing the free text that provides the same information as the observation within the narrative portion of the document with a <text> element. For CDA based uses of Observation Requests, this element SHALL be present, and SHALL contain a <reference> element that points to the related string in the narrative portion of the document. For HL7 Version 3 based uses, the <text> element MAY be included.

<statusCode code='active'/>

The <statusCode> element shall be present and shall describe the current state of the observation. Goals, intents and proposals that are available for action shall have an 'active' status, but other status values are permitted.

<effectiveTime value=' '/>

The <effectiveTime> element shall be present in observation requests to indicate the date and time when the measurement should be taken.

<value xsi:type=' ' …/>

The value of the observation may be recorded using a data type appropriate to the observation to indicate the desired value (e.g., in GOL or PRP mood).

<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>

The methodCode element may be used to record the specific method used to make an observation when this information is not already pre-coordinated with the observation code .

<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The targetSiteCode may be used to record the target site where the observation should be made when this information is not already pre-coordinated with the observation code.

<author><assignedAuthor classCode='ASSIGNED'>...<assignedAuthor></author>

In CDA uses, the observation request is assumed to be authored by the same author as the document through context conduction. However, observation requests would often be used to record orders, and in these cases, the author of the order shall be recorded in the author element.

For HL7 Version 3 purposes, the <author> element SHOULD be present unless it can be determined by conduction from organizers or higher level structures. When used for HL7 Version 3 the role element name is <assignedEntity> and the author is represented a <assignedPerson> element.

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