2.16.840.1.113883.10.22.3.14

From HL7 IPS
Revision as of 20:04, 27 March 2018 by ADbot (talk | contribs) (Automated ADBot page content)
Jump to: navigation, search
Comments on this page

Template IPSResultsSection

Description

Keine Beschreibung in Deutsch (de-DE) verfügbar
en-US: 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).

Actual version

Id2.16.840.1.113883.10.22.3.14Effective Date2017‑04‑30
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSResultsSectionDisplay NameIPS 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).
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.14
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
hl7ips-data​element-126Kyellow.png Observations results list Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-142Kyellow.png Result Description Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-19Kyellow.png Results Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 4 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.9ContainmentKorange.png IPS Result Organizer (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKyellow.png IPS Translation Section (2021)DYNAMIC
RelationshipAdaptation: 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>
ItemDTCardConfDescriptionLabel
hl7:section
(IPS...ion)
 
Target.png
hl7ips-data​element-19Kyellow.png Results Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.png@moodCode
cs0 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1R(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.14
Treetree.pnghl7:id
II0 … *R(IPS...ion)
Treetree.pnghl7:code
CE.IPS1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F30954-2
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1M(IPS...ion)
Treetree.pnghl7:text
SD.TEXT1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-142Kyellow.png Result Description Kyellow.png CEN/TC 251 prEN 17269
Included0 … * from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *(IPS...ion)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ion)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ion)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ion)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(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)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ion)
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(IPS...ion)
Treetree.pnghl7:entry
1 … *MContains 2.16.840.1.113883.10.22.4.9 IPS Result Organizer (DYNAMIC)(IPS...ion)
 
Target.png
hl7ips-data​element-126Kyellow.png Observations results list Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7: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

Retrieved from "http://wiki.international-patient-summary.net/index.php?title=2.16.840.1.113883.10.22.3.14&oldid=4747"