2.16.756.5.30.1.1.10.4.3

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Vorlage:Templatenote

Template chpalm_entry_LaboratoryObservation

Actual version

Template CDA-CH Laboratory Observation / cdach_entry_LaboratoryObservation
Id2.16.756.5.30.1.1.10.4.3
Version gültig ab 2016‑03‑24 13:20:18 Status Kyellow.png In Entwicklung
KlassifikationCDA Entry Level Template
KontextElternknoten des Template-Element mit Id 2.16.756.5.30.1.1.10.4.3
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Beschreibung
Benutzt von / Benutzt
Benutzt von 0 Templates, Benutzt 3 Templates
Benutzt Template-Id als NameVersion
2.16.756.5.30.1.1.10.9.14Inklusioncdach_other_TextElementWithReferenceToNarrativeText DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.2ContainmentAnnotationComment DYNAMIC
1.3.6.1.4.1.19376.1.3.1.6ContainmentLaboratoryObservation DYNAMIC
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Spezialisierung: Template 1.3.6.1.4.1.19376.1.3.1.6 (2008‑08‑08)
ItemDTKardKonfBeschreibungLabel
hl7:observation
1 .. 1M(cdach_entry_LaboratoryObservation)
Treetree.png@classCode
cs1 .. 1FOBS
Treetree.png@moodCode
cs1 .. 1FEVN
Treetree.pnghl7:templateId
II1 .. 1M(cdach_entry_LaboratoryObservation)
Treeblank.pngTreetree.png@root
uid1 .. 1F2.16.756.5.30.1.1.10.4.3
Treetree.pnghl7:templateId
II1 .. 1M(cdach_entry_LaboratoryObservation)
Treeblank.pngTreetree.png@root
uid1 .. 1F1.3.6.1.4.1.19376.1.3.1.6
Treetree.pnghl7:id
II0 .. 1EN-US.png A Laboratory Observation identifier MAY be present.(cdach_entry_LaboratoryObservation)
Treetree.pnghl7:code
CE1 .. 1M(cdach_entry_LaboratoryObservation)
Eingefügt von 2.16.756.5.30.1.1.10.9.14 CDA-CH Narrative text reference (DYNAMIC) 1..1 Notwendig
Treetree.pnghl7:text
ED1 .. 1M(cdach_entry_LaboratoryObservation)
Treeblank.pngTreetree.pnghl7:reference
TEL1 .. 1M(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreetree.png@value
1 .. 1R
Treetree.pnghl7:statusCode
CS1 .. 1EN-US.png A Laboratory Observation statusCode SHALL be either "completed" or "aborted".
  • 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.
(cdach_entry_LaboratoryObservation)
 CONF
@code muss "completed" sein
oder
@code muss "aborted" sein
Treetree.pnghl7:effectiveTime
TS0 .. 1NPEN-US.png A Laboratory Observation MAY contain a relevant clinical time (ideally specimen collection time).(cdach_entry_LaboratoryObservation)
Auswahl max 1 Element(e). Elemente in der Auswahl:
  • hl7:value[@xsi:type='BL']
  • hl7:value[@xsi:type='ED']
  • hl7:value[@xsi:type='CD']
  • hl7:value[@xsi:type='PQ']
  • hl7:value[@xsi:type='RTO']
Treeblank.pngTreetree.pnghl7:value
wo
[@xsi:type='BL']
BL0 .. 1R(cdach_entry_LaboratoryObservation)
 Beispiel
true/false result
<value xsi:type="BL" value="false"/>
Treeblank.pngTreetree.pnghl7:value
wo
[@xsi:type='ED']
ED0 .. 1R(cdach_entry_LaboratoryObservation)
 Beispiel
Text result
<value xsi:type="ED">
  <reference value="#l1"/>
</value>
Treeblank.pngTreetree.pnghl7:value
wo
[@xsi:type='CD']
CD0 .. 1R(cdach_entry_LaboratoryObservation)
 Beispiel
Coded result
<value xsi:type="CD" code="N" codeSystem="2.16.756.5.30.2.1.1.3.1"/>
Treeblank.pngTreetree.pnghl7:value
wo
[@xsi:type='PQ']
PQ0 .. 1R(cdach_entry_LaboratoryObservation)
 Beispiel
Physical quantity with unit
<value xsi:type="PQ" value="6.4" unit="mg/dL"/>
Treeblank.pngTreetree.pnghl7:value
wo
[@xsi:type='RTO']
RTO0 .. 1R(cdach_entry_LaboratoryObservation)
 Beispiel
Titer
<value xsi:type="RTO">
  <numerator xsi:type="INT" value="1"/>
  <denominator xsi:type="INT" value="64"/>
</value>
Treetree.pnghl7:interpretationCode
CE0 .. 1R(cdach_entry_LaboratoryObservation)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.10609 NullFlavor (DYNAMIC)
Treetree.pnghl7:methodCode
CE0 .. 1EN-US.png 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.(cdach_entry_LaboratoryObservation)
Treetree.pnghl7:subject
0 .. 1EN-US.png Subject in case of a non-human subject attached to the Observation(cdach_entry_LaboratoryObservation)
Treeblank.pngTreetree.png@typeCode
cs1 .. 1FSBJ
Treetree.pnghl7:specimen
0 .. 1EN-US.png A Laboratory Observation MAY contain specimen documentation when it is different from the one documented at a higher level.(cdach_entry_LaboratoryObservation)
Treeblank.pngTreetree.png@typeCode
cs1 .. 1FSPC
Treeblank.pngTreetree.pnghl7:specimenRole
0 .. 1(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 .. 1FSPEC
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 .. 1EN-US.png specimen identifier known to the laboratory(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreetree.pnghl7:specimenPlayingEntity
1 .. 1(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE1 .. 1MEN-US.png The specimen type coded with HL7 vocabulary SpecimenEntityType or another standard vocabulary(cdach_entry_LaboratoryObservation)
 CONF
muss aus der Konzeptdomäne "Specimen Entity Type" gewählt werden
Treeblank.pngTreeblank.pngTreetree.pnglab:productOf
0 .. 1EN-US.png Extension to CDA Clinical Statement(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 .. 1FPRD
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnglab:procedure
(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 .. 1FPROC
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 .. 1FEVN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnglab:code
CE0 .. 1(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnglab:effectiveTime
IVL_TS1 .. 1M(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnglab:targetSiteCode
CD0 .. *(cdach_entry_LaboratoryObservation)
Treetree.pnghl7:performer
0 .. 1EN-US.png 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.(cdach_entry_LaboratoryObservation)
Treeblank.pngTreetree.png@typeCode
cs1 .. 1FPRF
Treetree.pnghl7:author
0 .. *REN-US.png 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.(cdach_entry_LaboratoryObservation)
Treeblank.pngTreetree.png@typeCode
cs1 .. 1FAUT
Auswahl max 3 Element(e). Elemente in der Auswahl:
  • hl7:participant[@typeCode='AUTHEN']
  • hl7:participant[@typeCode='RESP']
  • hl7:participant[@typeCode='DEV']
Treeblank.pngTreetree.pnghl7:participant
wo
[@typeCode='AUTHEN']
0 .. 1EN-US.png The verifier of the observations of this part of the report. In the case where a laboratory report has multiple verifiers. Each verifier is attached to the subset of observations he or she verified, by the means of a <participant> element.(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 .. 1FAUTHEN
Treeblank.pngTreetree.pnghl7:participant
wo
[@typeCode='RESP']
0 .. 1EN-US.png The person responsible for the provision of the observations of this part of the report. In the case where a subset of the observations is subcontracted to an external laboratory, this external laboratory (with its address and telcom) and the actual performer is represented by a <performer> element, whereas the Director of this subcontractor laboratory is carried by the <participant> element being attached to the same level as the <performer> element.(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 .. 1FRESP
Treeblank.pngTreetree.pnghl7:participant
wo
[@typeCode='DEV']
0 .. 1EN-US.png A device or equipment, which was used to produce this set of results (e.g. an analyzer).(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 .. 1FDEV
Treetree.pnghl7:entryRelationship
wo
[@typeCode='COMP']
0 .. *REN-US.png A Laboratory Observation MAY contain test comments that shall be recorded using the Annotation Comment template within the Laboratory Observation as shown above.(cdach_entry_LaboratoryObservation)
Treeblank.pngTreetree.png@typeCode
cs1 .. 1FCOMP
 Beinhaltet 1.3.6.1.4.1.19376.1.5.3.1.4.2 Annotation Comment (DYNAMIC)
Treetree.pnghl7:entryRelationship
wo
[@typeCode='REFR']
0 .. *REN-US.png 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.(cdach_entry_LaboratoryObservation)
Treeblank.pngTreetree.png@typeCode
cs1 .. 1FREFR
 Beinhaltet 1.3.6.1.4.1.19376.1.3.1.6 Laboratory Observation (DYNAMIC)
Treetree.pnghl7:referenceRange
0 .. 1REN-US.png 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.(cdach_entry_LaboratoryObservation)
Treeblank.pngTreetree.png@typeCode
cs1 .. 1FREFV
Treeblank.pngTreetree.pnghl7:observationRange
1 .. 1(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 .. 1FOBS
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 .. 1FEVN.CRT
 Constraint
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
0 .. 1(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretationCode
CV1 .. 1R(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
1 .. 1FN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 .. 1F2.16.840.1.113883.5.83
Treeblank.pngTreeblank.pngTreetree.pnglab:precondition
0 .. *EN-US.png Extension to CDA Clinical statement(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 .. 1FPRCN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnglab:criterion
1 .. 1(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 .. 1FCOND
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 .. 1FEVN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnglab:code
CE1 .. 1REN-US.png Code of the criterion (e.g. age, sex)(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnglab:value
1 .. 1R(cdach_entry_LaboratoryObservation)
 Schematron assertroleKred.png error 
 testnot(cda:value[@xsi:type=('PQ','INT')]) or (cda:referenceRange[@typeCode='REFV']/cda:observationRange[@classCode='OBS' and @moodCode='EVN.CRT' and cda:value[@xsi:type='IVL_PQ' and cda:low and cda:high] and cda:interpretationCode[@code='N' and @codeSystem='2.16.840.1.113883.5.83']]) 
 MeldungZu einem Laborresultat mit Datentyp PQ oder INT muss der Referenzbereich für normale Werte angegeben werden. 
Eingefügt von 1.3.6.1.4.1.19376.1.5.3.1.4.2 Annotation Comment (DYNAMIC) 0..*
Treetree.pnghl7:act
0 .. *EN-US.png The related statement is an event (moodCode='EVN') describing the act (classCode='ACT') of making an arbitrary comment or providing instruction on the related entry.(cdach_entry_LaboratoryObservation)
Treeblank.pngTreetree.png@classCode
1 .. 1FACT
Treeblank.pngTreetree.png@moodCode
1 .. 1FEVN
Treeblank.pngTreetree.pnghl7:templateId
II1 .. 1R(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreetree.png@root
1 .. 1F2.16.840.1.113883.10.20.1.40
Treeblank.pngTreetree.pnghl7:templateId
II1 .. 1R(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreetree.png@root
1 .. 1F1.3.6.1.4.1.19376.1.5.3.1.4.2
Treeblank.pngTreetree.pnghl7:code
CD1 .. 1MEN-US.png The <code> element indicates that this is a comment and shall be recorded as shown above. The codeSystem and code attributes shall use the values specified above.(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreetree.png@code
1 .. 1F48767-8
Treeblank.pngTreeblank.pngTreetree.png@codeSystem
1 .. 1F2.16.840.1.113883.6.1
Treeblank.pngTreeblank.pngTreetree.png@displayName
1 .. 1FAnnotation Comment
Treeblank.pngTreeblank.pngTreetree.png@codeSystemName
1 .. 1FLOINC
Treeblank.pngTreetree.pnghl7:text
ED1 .. 1MEN-US.png The <text> element provides a way to represent the <reference> to the text of the comment in the narrative portion of the document. For CDA, this SHALL be represented as a <reference> element that points to the narrative text section of the CDA. The comment itself is not the act being coded, so it appears in the <text> of the <observation>, not as part of the <code>. For HL7 Version 3 Messages, the <text> element SHALL contain the full narrative text.(cdach_entry_LaboratoryObservation)
Treeblank.pngTreetree.pnghl7:statusCode
CS1 .. 1MEN-US.png The code attribute of <statusCode> for all comments must be completed.(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreetree.png@code
1 .. 1Fcompleted
Treeblank.pngTreetree.pnghl7:author
0 .. 1REN-US.png The comment may have an author.(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreetree.png@typeCode
0 .. 1FAUT
Treeblank.pngTreeblank.pngTreetree.pnghl7:time
TS0 .. 1REN-US.png The time of the comment creation shall be recorded in the <time> element when the <author> element is present.(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreetree.pnghl7:assignedAuthor
1 .. 1MEN-US.png The identifier of the author, and their address and telephone number must be present inside the <id>, <addr> and <telecom> elements when the <author> element is present.(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 .. 1FASSIGNED
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 .. 1R(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 .. 1R(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 .. 1R(cdach_entry_LaboratoryObservation)
Auswahl min 1 Element(e) und max 2 Element(e). Elemente in der Auswahl:
  • hl7:assigned​Person
  • hl7:represented​Organization
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 .. 1R(cdach_entry_LaboratoryObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 .. 1R(cdach_entry_LaboratoryObservation)

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