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
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=" "/>
<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>
|
<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=" "/>
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 and has no result. A status of obsolete means the test result has been replaced by a newer observation (following it) in this revision of the report and has no result.
NOTE: Simple Observation requires the status of "completed".
NOTE: Lab TF says that "obsolete" results do not have values - I disagree. (??)
<effectiveTime value=" "/>
The observation's relevant clinical time (ideally specimen collection time) MAY be present.
NOTE: Simple Observation requires the presence of effectiveTime and if the value is unknown, nullFlavor is used.
<value xsi:type=" " …/>
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: Lab TF says that "obsolete" results do not have values - I disagree. (??)
<interpretationCode code=" " codeSystem=" "/>=
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 MAY be recorded using the Observation Method vocabulary (CWE). The method could be explicit when LOINC vocabulary is used for the observation code.
<entryRelationship typeCode="COMP">
Test comments shall be recorded using the Annotation Comment template within the observation as shown above.
<entryRelationship typeCode="REFR">
An 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.