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Id2.16.840.1.113883.10.22.4.12Gültigkeit ab2024‑08‑04 20:18:00
StatusKyellow.png EntwurfVersions-LabelSTU2
NameIPSRadiologyResultObservationBezeichnungIPS Radiology Result Observation
Beschreibung
EN-US.png This template represents an observation produced as one of the results of a radiology or other imaging study performed on a patient. 
In most cases, in the context of a patient summary this observation is final and validated, which is recorded with the value "completed" in the statusCode element. Should  the observation be not final, the statusCode would indicate "active", instead.
KontextElternknoten des Template-Element mit Id 2.16.840.1.113883.10.22.4.12
KlassifikationCDA Entry Level Template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Benutzt
Benutzt 3 Templates
Benutzt als NameVersion
2.16.840.1.113883.10.22.4.14InklusionKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.22.17ContainmentKyellow.png IPS Radiology Result Observation Component (STU2)DYNAMIC
2.16.840.1.113883.10.22.4.22ContainmentKorange.png IPS Comment Activity (STU1)DYNAMIC
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.22.4.12 IPS Radiology Result Observation (2017‑03‑21)
ref
hl7ips-

Adaptation: Template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-

Adaptation: Template 2.16.840.1.113883.10.20.22.4.2 Result Observation (V3) (2015‑08‑01)
ref
ccda-

Adaptation: Template 2.16.840.1.113883.10.22.4.10 IPS Result Observation (2017‑03‑02)
ref
hl7ips-
ItemDTKardKonfBeschreibungLabel
hl7:observation
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.12
Treetree.pnghl7:id
II0 … *R
Treetree.pnghl7:code
CD.IPS (extensible)1 … 1M
 CONF
Der Wert von @code SOLLTE gewählt werden aus dem Value Set 2.16.840.1.113883.11.22.40 IPS Results Radiology Observation (DYNAMIC)
Treetree.pnghl7:statusCode
CS1 … 1M
 CONF
Der Wert von @code MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1R
Treetree.pnghl7:value
ST0 … 1REN-US.png Actual result, free text (data type ST)
Treetree.pnghl7:interpretationCode
CE.IPS0 … 1R
 CONF
Der Wert von @code MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)
Treetree.pnghl7:target​Site​Code
CD.IPS (preferred)0 … 1
 ConstraintEN-US.png If the observation site is not precoordinated in the observation/code or observation/value it SHALL be specified in the observation/targetSiteCode
 CONF
Der Wert von @code kommt vorzugsweise aus dem Value Set 2.16.840.1.113883.11.22.55 IPS Body Site (DYNAMIC)
Treeblank.pngTreetree.pnghl7:qualifier
CR0 … 1EN-US.png Laterality
 ConstraintEN-US.png The qualifier element for laterality SHALL be present if the targetSiteCode represents a paired body part and laterality is not pre-coordinated in the targetSiteCode
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV (preferred)1 … 1M
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF1 … 1F272741003
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.96 (SNOMED Clinical Terms)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD.IPS (preferred)1 … 1M
 CONF
Der Wert von @code kommt vorzugsweise aus dem Value Set 2.16.840.1.113883.11.22.57 Laterality (qualifier) (DYNAMIC)
Treeblank.pngTreetree.pnghl7:qualifier
CR0 … 1EN-US.png Topographical modifier
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV (preferred)1 … 1M
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF1 … 1F106233006
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.96 (SNOMED Clinical Terms)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD.IPS (preferred)1 … 1M
 CONF
Der Wert von @code kommt vorzugsweise aus dem Value Set 2.16.840.1.113883.11.22.58 Topographical modifier (qualifier) (DYNAMIC)
Eingefügt0 … *R von 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *R
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R
Auswahl0 … 1Elemente in der Auswahl:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C
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 … *REN-US.png Name of the person (e.g. the Healthcare Professional)  authoring this document
 Beispiel<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7: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)
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
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *
Treetree.pnghl7:referenceRange
0 … *R
Treeblank.pngTreetree.pnghl7:observationRange
1 … 1M
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CDNP
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
ANY1 … 1M
Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretationCode
CE0 … 1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF0 … 1FN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.5.83 (Observation Interpretation)
Treetree.pnghl7:entryRelationship
0 … *Beinhaltet 2.16.840.1.113883.10.22.17 IPS Radiology Result Observation Component (DYNAMIC)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7:entryRelationship
0 … *Beinhaltet 2.16.840.1.113883.10.22.4.22 IPS Comment Activity (DYNAMIC)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
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