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"/> <code code="23749-5" 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"/>

<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 id should be present if one is known.

NOTE: Simple Observation requires the use of id.

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

<statusCode code="completed"/>

The observation 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 A status of obsolete means the test has been replaced by a newer observation (following it) in this revision of the report.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 relevant clinical time (ideally specimen collection time).

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 observation result using the appropriate data type. Numeric results shall use data type "PQ" as shown above. 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. In the case of microbiology, use ObservationInterpretationSusceptibility (S = susceptible, R = resistant, I = intermediate, VS = very susceptible, MS = moderately susceptible).

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

The test method should be recorded using the Observation Method vocabulary (CWE). The method may be explicit based on the LOINC observation code.