1.3.6.1.4.1.19376.1.5.3.1.3.28

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Trial.gif Coded Results Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.3.28
General Description The results section shall contain a narrative description of the relevant diagnostic procedures the patient received in the past. It shall include entries for procedures and references to procedure reports when known as described in the Entry Content Modules.
LOINC Code Opt Description
30954-2 R STUDIES SUMMARY
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.19 R Procedure Entry
1.3.6.1.4.1.19376.1.5.3.1.4.4 R2 References Entry
1.3.6.1.4.1.19376.1.5.3.1.4.13 O Simple Observation



Sample Coded Results Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.28'/>
    <id root=' ' extension=' '/>
    <code code='30954-2' displayName='STUDIES SUMMARY'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Procedure Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
         :
    </entry> 
    <entry>
         :
      <!-- Required if known References Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
         :
    </entry> 
    <entry>
         :
      <!-- Optional Simple Observation element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.3.28'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.3.28"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Coded Results can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "30954-2"]'> 
     Error: The section type code of a Coded Results must be 30954-2 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Coded Results Section must contain a(n) Procedure Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.28
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Coded Results Section should contain a(n) References Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.28
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.4.13"]'> 
     <!-- Note any missing optional elements -->
     Note: This Coded Results Section does not contain a(n) Simple Observation Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.28
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Coded Results Section


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