1.3.6.1.4.1.19376.1.3.1.6

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Laboratory Observation 1.3.6.1.4.1.19376.1.3.1.6

Example Description

Standards

CareStruct	HL7 Care Provision Care Structures (DSTU)
CCD	ASTM/HL7 Continuity of Care Document

Parent Template

The parent of this template is Parent Template Name.

Uses

See Templates using Laboratory Observation

Specification

Laboratory Observation Example

<ClinicalDocument ... <component typeCode="COMP"> <structuredBody classCode="DOCBODY" moodCode="EVN"> <component typeCode="COMP"> <section classCode="DOCSECT"> ... <entry typeCode="DRIV"> <templateId extension="Lab.Report.Data.Processing.Entry" root="1.3.6.1.4.1.19376.1.3.1"/> <act classCode="ACT" moodCode="EVN"> ... <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN"> <templateId root="1.3.6.1.4.1.19376.1.3.1.6"/> <id root=" " extension=" "/> <code code="10912-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Lead Measurement, Quantitative"> <originalText><reference value="pbTest"/></originalText> </code> <statusCode code="completed"/> <effectiveTime value="20071108000000.0000-0500"/> <value xsi:type="PQ" unit="mg/dL" value="7.4"/> <interpretationCode code="H" codeSystem="2.16.840.1.113883.5.83"/> <methodCode code=" " codeSystem=" " codeSystemName=" "/> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN"> <templateId root='2.16.840.1.113883.10.20.1.40'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/> <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation Comment"/> <text><reference value="pbTestComment"/></text> <statusCode code="completed"/> </act> </entryRelationship> </observation>

<observation classCode="OBS" moodCode="EVN">

The observation shall be recorded as shown above, classCode "OBS" and moodCode "EVN".

NOTE: Simple Observation uses typeCode OBS, rather than classCode OBS.

<templateId root='1.3.6.1.4.1.19376.1.3.1.6'/>

The <templateId> element identifies this <observation> as a Laboratory Observation. The templateId shall be recorded as shown above, root='1.3.6.1.4.1.19376.1.3.1.6'.

<id root=" " extension=" "/>

The observation identifier may be present.

NOTE: Simple Observation requires the use of an identifier.

The unique test code from an international standard, such as LOINC, shall be present.

<statusCode code="completed"/>

The test status shall be either "completed", "aborted", or "obsolete". A status of completed means the test was performed and results obtained. A status of aborted means the test could not be performed. A status of obsolete means the test result has been replaced by a newer observation (following it) in this revision of the report.

NOTE: Simple Observation requires the status of "completed".

<effectiveTime value="20071108000000.0000-0500"/>

The observation's relevant clinical time (ideally specimen collection time) should be present.

NOTE: Simple Observation requires the presence of effectiveTime and if the value is unknown, nullFlavor is used.

<value xsi:type="PQ" unit="mg/dL" value="7.4"/>

The test result using the appropriate data type. Numeric results shall use data type "PQ" as shown above as it includes units. The result is absent in the case of "obsolete" or "aborted" observations.

NOTE: I disagree that results should be removed in the case of aborted tests. (??)

<interpretationCode code="H" codeSystem="2.16.840.1.113883.5.83"/>=

If there is an interpretation that can be performed using an observation result (e.g., low, high), one or more ObservationInterpretation vocabulary should be recorded within the interpretationCode element.

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

The test method should be recorded using the Observation Method vocabulary (CWE). The method may be explicit when LOINC observation codes are used for the observation code.

<entryRelationship>

Test comments shall be recorded using the Annotation Comment template within the observation as shown above.