2.16.840.1.113883.10.22.3.14

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Template IPSResultsSection

Description

Template CDA Section (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF)

Actual version

Id	2.16.840.1.113883.10.22.3.14	Effective Date	2017‑04‑30
Status	Under pre-publication review	Version Label	STU1
Name	IPSResultsSection	Display Name	IPS Results Section
Description This section assembles relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results may be laboratory results, others may be anatomic pathology results, others, radiology results, and others, clinical results. The structured, machine-processable content of this section is sorted out between as many Result Organizer entries as needed. One Result Organizer entry groups results, which have a common context of production: common specialty (imaging, bacteriology, serology, chemistry,  surgical pathology, clinical, radiology ...),  common overall interpretation, (which interprets the set of results of the Organizer), common biologic specimen for in vitro diagnostic observations,  common associated illustrative image. The optional author and informant elements of the section are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header. In case this section assembles results from multiple authors (e.g.; results authored by a clinical laboratory, and results produced by a radiology center), the authors are listed in the section, and each Result Organizer of the section indicates its own author(s).
Context	Parent nodes of template element with id 2.16.840.1.113883.10.22.3.14
Classification	CDA Section Level Template
Open/Closed	Open (other than defined elements are allowed)
Associated with	Associated with 3 concepts Id Name Data Set hl7ips-data​element-126  Observations results list  CEN/TC 251 prEN 17269 hl7ips-data​element-142  Result Description  CEN/TC 251 prEN 17269 hl7ips-data​element-19  Results  CEN/TC 251 prEN 17269
Uses	Uses 4 templates Uses as Name Version 2.16.840.1.113883.10.22.4.14 Include IPS Body Author (STU1) DYNAMIC 2.16.840.1.113883.10.12.319 Containment CDA Informant (Body) DYNAMIC 2.16.840.1.113883.10.22.4.9 Containment IPS Result Organizer (STU1) DYNAMIC 2.16.840.1.113883.10.22.3.15 Containment IPS Translation Section (2021) DYNAMIC
Relationship	Adaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07) ref ad1bbr-
Example	Example <section classCode="DOCSECT" moodCode="EVN">   <templateId root="2.16.840.1.113883.10.22.3.14"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="30954-2" codeSystem="2.16.840.1.113883.6.1" displayName="Relevant diagnostic tests/laboratory data Narrative"/>  <title>MOST SIGNIFICANT RESULTS</title>  <text>     <!-- some clinical laboratory results and some surgical pathology results presented to the human reader -->   </text>  <author>     <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 1st author: a clinical lab director -->   </author>  <author>     <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 2nd author: a pathologist -->   </author>  <entry typeCode="COMP" contextConductionInd="true">     <!--- 1st Organizer: chemistry observations on blood serum specimen produced and interpreted by a clinical laboratory -->     <organizer classCode="BATTERY" moodCode="EVN">       <templateId root="2.16.840.1.113883.10.22.4.9"/>      <code code="18719-5" displayName="Chemistry studies (set)" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>      <satusCode code="completed"/>      <author>         <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 1st author: a clinical lab director -->       </author>      <component>         <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->       </component>      <component>         <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->       </component>      <component>         <!-- template 2.16.840.1.113883.10.22.4.30 'IPS Specimen Collection' - common blood serum specimen -->       </component>      <component>         <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' - interpretation of chemistry results -->       </component>    </organizer>  </entry>  <entry>     <organizer classCode="BATTERY" moodCode="EVN">       <templateId root="2.16.840.1.113883.10.22.4.9"/>      <code code="18723-7" displayName="Hematology studies (set)" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>      <satusCode code="completed"/>      <author>         <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 1st author: a clinical lab director -->       </author>      <component>         <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->       </component>      <component>         <!-- template 2.16.840.1.113883.10.22.4.13 'IPS Laboratory Result Observation' -->       </component>      <component>         <!-- template 2.16.840.1.113883.10.22.4.30 'IPS Specimen Collection' - venous blood total specimen -->       </component>      <component>         <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' - interpretation of hematology results -->       </component>    </organizer>  </entry>  <entry>     <organizer classCode="BATTERY" moodCode="EVN">       <templateId root="2.16.840.1.113883.10.22.4.9"/>      <code code="11529-5" displayName="Surgical pathology studies (set)" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>      <satusCode code="completed"/>      <author>         <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' - 2nd author: a pathologist -->       </author>      <component>         <!-- template 2.16.840.1.113883.10.22.4.11 'IPS Pathology Result Observation' -->       </component>      <component>         <!-- template 2.16.840.1.113883.10.22.4.30 'IPS Specimen Collection' - excised tissue specimen -->       </component>      <component>         <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' - pathologist's interpretation -->       </component>      <component>         <!-- template 2.16.840.1.113883.10.22.4.23 'IPS ObservationMedia' - an illustrative slide image -->       </component>    </organizer>  </entry></section>
Item DT Card Conf Description Label hl7:section (IPS...ion)   hl7ips-data​element-19  Results  CEN/TC 251 prEN 17269 @classCode cs 0 … 1 F DOCSECT @moodCode cs 0 … 1 F EVN hl7:templateId II 1 … 1 R (IPS...ion) @root uid 1 … 1 F 2.16.840.1.113883.10.22.3.14 hl7:id II 0 … * R (IPS...ion) hl7:code CE.IPS 1 … 1 M (IPS...ion) @code CONF 1 … 1 F 30954-2 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (LOINC) hl7:title ST 1 … 1 M (IPS...ion) hl7:text SD.TEXT 1 … 1 M (IPS...ion)   hl7ips-data​element-142  Result Description  CEN/TC 251 prEN 17269 Included 0 … * from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC) hl7:author 0 … * (IPS...ion) hl7:templateId II 1 … 1 M (IPS...ion) @root uid 1 … 1 F 2.16.840.1.113883.10.22.4.14 hl7:time TS.IPS.TZ 1 … 1 R (IPS...ion) hl7:assignedAuthor 1 … 1 M (IPS...ion) hl7:id II 1 … * R (IPS...ion) hl7:code 0 … 1 R (IPS...ion) Choice 0 … 1 Elements to choose from: hl7:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 0 … 1 C (IPS...ion) @classCode cs 0 … 1 F PSN @determiner​Code cs 0 … 1 F INSTANCE hl7:name PN 1 … * R Name of the person (e.g. the Healthcare Professional)  authoring this document (IPS...ion)   Example <name>   <given>John</given>  <family>Español Smith</family></name> hl7:family 1 … * R (IPS...ion) hl7:given 1 … * R (IPS...ion) hl7:assigned​Authoring​Device 0 … 1 C (IPS...ion)   Example <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">   <softwareName displayName="Turriano"/></assignedAuthoringDevice> Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC) @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:code CE 0 … 1 (IPS...ion) hl7:manufacturer​Model​Name SC 0 … 1 (IPS...ion) hl7:softwareName SC 0 … 1 (IPS...ion) hl7:represented​Organization 0 … 1 (IPS...ion) hl7:id II 0 … * (IPS...ion) hl7:name 0 … * (IPS...ion) hl7:telecom TEL 0 … * (IPS...ion) hl7:addr AD 0 … * (IPS...ion) hl7:informant 0 … * Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC) (IPS...ion) hl7:entry 1 … * M Contains 2.16.840.1.113883.10.22.4.9 IPS Result Organizer (DYNAMIC) (IPS...ion)   hl7ips-data​element-126  Observations results list  CEN/TC 251 prEN 17269 @typeCode cs 1 … 1 R   CONF The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC) @context​Conduction​Ind bl 0 … 1 F true hl7:component 0 … * Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC) (IPS...ion)

List of all versions of this template

• 2017-04-30 (Under develeopment)