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Revision as of 15:01, 13 June 2008
Return to: PCC TF-1/PHLAB/XDSLAB Harmonization
Return to: Laboratory Data Processing Entry
Development Only
The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC
Laboratory Observation 1.3.6.1.4.1.19376.1.3.1.6
The Laboratory Observation entry shall record a single laboratory observation in the document, either standalone or as part of a battery. It is very similar to the Simple Observation so the differences are highlighted below. The figure below shows how the information for this element is coded, and further constraints are provided in the following sections.
Standards
| CRS | HL7 Care Record Summary |
Uses
See Templates using Laboratory Observation
Specification
<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="6.4"/>
<interpretationCode code="H" codeSystem="2.16.840.1.113883.5.83"/>
<methodCode code=" " codeSystem=" " codeSystemName=" "/>
<specimen typeCode="SPC">
<specimenRole classCode="SPEC">
<id extension="555847399003" root="1.19.6.11.13"/>
<specimenPlayingEntity>
<code code="BLD" codeSystem="2.16.840.1.113883.5.129" codeSystemName="HL7" displayName="Blood"/>
</specimenPlayingEntity>
</specimenRole>
</specimen>
<performer typeCode="PRF">
<templateId extension=??" root="1.3.6.1.4.1.19376.1.3.3.1.7"/>
...
</performer>
<author typeCode="AUT">
...
</author>
<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>
<entryRelationship typeCode="REFR">
<sequenceNumber value="1"/>
<observation classCode="OBS" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.3.1.6"/>
<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="20071101000000.0000-0500"/>
<value xsi:type="PQ" unit="mg/dL" value="8.7"/>
<interpretationCode code="H" codeSystem="2.16.840.1.113883.5.83"/>
<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>
</entryRelationship>
<referenceRange typeCode="REFV">
<observationRange classCode="OBS" moodCode="EVN.CRT">
<value xsi:type="IVL_PQ">
<low value="0.0" unit="mg/dL"/>
<high value="5.0" unit="mg/dL"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
</observationRange>
<precondition typeCode="PRCN">
<criterion classCode="COND" moodCode="ENV">
<code code="AGE"/>
<value xsi:type="IVL_PQ">
<low value="0" unit="Y"/>
<high value="18" unit="Y"/>
</value>
</criterion>
</precondition>
</referenceRange>
</observation>
|
<observation classCode="OBS" moodCode="EVN">
A Laboratory 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=" "/>
A Laboratory Observation identifier MAY be present.
NOTE: Simple Observation requires the use of an identifier.
A Laboratory Observation shall contain a unique test code from an international standard, such as LOINC.
<statusCode code=" "/>
A Laboratory Observation statusCode 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 and has no value. A status of obsolete means the Laboratory Observation has been replaced by a newer Laboratory Observation (following it) in this revision of the report.
NOTE: Simple Observation requires the status of "completed".
<effectiveTime value=" "/>
A Laboratory Observation MAY contain a relevant clinical time (ideally specimen collection time).
NOTE: Simple Observation requires the presence of effectiveTime. If the value is unknown, nullFlavor shall be used.
<value xsi:type=" " …/>
A Laboratory Observation value 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 "aborted" observations.
<interpretationCode code=" " codeSystem=" "/>=
A Laboratory Observation MAY contain an interpretation of the Laboratory Observation result (e.g., low, high). One or more ObservationInterpretation vocabulary MAY be recorded within the interpretationCode element.
<methodCode code=" " codeSystem=" " codeSystemName=" "/>
A Laboratory Observation MAY contain a methodCode using the Observation Method vocabulary (CWE). The method MAY be explicit when LOINC vocabulary is used for the Laboratory Observation code.
<specimen typeCode="SPC"><specimenRole classCode="SPEC">...</specimen>
A Laboratory Observation MAY contain specimen documentation when it is different from the one documented at a higher level.
<performer typeCode="PRF"/>
A Laboratory Observation MAY contain the person who performed the test when it is different from the one documented at a higher level, including the header.
<author typeCode="AUT"/>
A Laboratory Observation shall contain author(s) of the Laboratory Observation when multiple header author(s) exist and not all apply to this Laboratory Observation. The author/time element carries the date&time the laboratory report was produced by the system.
<entryRelationship><act><participant typeCode=" ">...</participant></act></entryRelationship>
A Laboratory Observation MAY contain up to 3 types of participants "AUTHEN", "RESP", "DEV".
NOTE: Lab TF still uses "VRF" instead of "AUTHEN" for authentication/verifying participants.
<entryRelationship typeCode="COMP">
A Laboratory Observation MAY contain test comments that shall be recorded using the Annotation Comment template within the Laboratory Observation as shown above.
NOTE: Lab TF says to use <entryRelationship typeCode="COMP"><act classCode="ACT" moodCode="EVN"><text/> to document comments.
<entryRelationship typeCode="REFR">
A Laboratory Observation MAY be complemented by any number of previous results as pertinent information related to it delivering the previous result from a separate specimen, and carrying the same test code. In case there is more than one previous result, the entryRelationship elements are sorted in reverse chronological order, numbered from 1 to n by sequenceNumber.
<referenceRange typeCode="REFV">
A Laboratory Observation MAY have a reference range representing a value, not text. The reference range MAY be qualified with pre-conditions, each of which has a criterion.