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1 Template IPSResultsSection

1.1 Aktuelle Version

Id2.16.840.1.113883.10.22.3.14Gültigkeit ab2017‑04‑30
Status  Unter Revision vor der PublikationVersions-LabelSTU1
NameIPSResultsSectionBezeichnungIPS Results Section
Beschreibung
  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).
KontextElternknoten des Template-Element mit Id 2.16.840.1.113883.10.22.3.14
KlassifikationCDA Section level template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Assoziiert mit
Assoziiert mit 3 Konzepte
IdNameDatensatz
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
Benutzt
Benutzt 4 Templates
Benutzt als NameVersion
2.16.840.1.113883.10.22.4.14Inklusion  IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319Containment  CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.9Containment  IPS Result Organizer (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.15Containment  IPS Translation Section (2021)DYNAMIC
BeziehungAdaptation: Template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
Beispiel
Beispiel
<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>
ItemDTKardKonfBeschreibungLabel
hl7:section
 
 
hl7ips-data​element-19  Results   CEN/TC 251 prEN 17269
 @classCode
cs0 … 1FDOCSECT
 @moodCode
cs0 … 1FEVN
 hl7:templateId
II1 … 1R
  @root
uid1 … 1F2.16.840.1.113883.10.22.3.14
 hl7:id
II0 … *R
 hl7:code
CE.IPS1 … 1M
  @code
CONF1 … 1F30954-2
  @codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
 hl7:title
ST1 … 1M
 hl7:text
SD.TEXT1 … 1M
 
 
hl7ips-data​element-142  Result Description   CEN/TC 251 prEN 17269
Eingefügt0 … * von 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
 hl7:author
0 … *
  hl7:templateId
II1 … 1M
   @root
uid1 … 1F2.16.840.1.113883.10.22.4.14
  hl7:time
TS.IPS.TZ1 … 1R
  hl7:assignedAuthor
1 … 1M
   hl7:id
II1 … *R
   hl7:code
0 … 1R
Auswahl0 … 1Elemente in der Auswahl:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
    hl7:assigned​Person
0 … 1C
     @classCode
cs0 … 1FPSN
     @determiner​Code
cs0 … 1FINSTANCE
     hl7:name
PN1 … *R  Name of the person (e.g. the Healthcare Professional)  authoring this document
 Beispiel<name>
  <given>John</given>  <family>Español Smith</family></name>
      hl7:family
1 … *R
      hl7:given
1 … *R
    hl7:assigned​Authoring​Device
0 … 1C
 Beispiel<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Eingefügt von 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
     @classCode
cs0 … 1FDEV
     @determiner​Code
cs0 … 1FINSTANCE
     hl7:code
CE0 … 1
     hl7:manufacturer​Model​Name
SC0 … 1
     hl7:softwareName
SC0 … 1
   hl7:represented​Organization
0 … 1
    hl7:id
II0 … *
    hl7:name
0 … *
    hl7:telecom
TEL0 … *
    hl7:addr
AD0 … *
 hl7:informant
0 … *Beinhaltet 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)
 hl7:entry
1 … *MBeinhaltet 2.16.840.1.113883.10.22.4.9 IPS Result Organizer (DYNAMIC)
 
 
hl7ips-data​element-126  Observations results list   CEN/TC 251 prEN 17269
  @typeCode
cs1 … 1R
 CONF
Der Wert von @typeCode MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
  @context​Conduction​Ind
bl0 … 1Ftrue
 hl7:component
0 … *Beinhaltet 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)


1.2 Zusammenstellung aller Versionen dieses Templates

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