2.16.840.1.113883.10.22.4.10

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1 Template IPSResultObservation

1.1 Aktuelle Version

Id	2.16.840.1.113883.10.22.4.10	Gültigkeit ab	2017‑03‑02
Status	Unter Revision vor der Publikation	Versions-Label	STU1
Name	IPSResultObservation	Bezeichnung	IPS Result Observation
Beschreibung This generic template is the basic set of constraints, which apply to any kind of observation grouped in a Result Organizer. The IPS Result Observation template is generic. It is further specialized by child templates, which  constrain  clinical laboratory observations or radiology observations or anatomic pathology observations. The generic IPS Result Observation template is usable in a patient summary for observations, which do not fall within one of the specialized categories.   The result observation includes a statusCode to allow recording the status of an observation. “Pending” results (e.g., a test has been run but results have not been reported yet) should be represented as “active” ActStatus. However, in most cases, observations selected for an international patient summary are  results that are final and approved, and thus, have a "completed" statusCode. The result of the observation may be commented through an entryRelationship introducing an "IPS Comment activity" template.
Kontext	Elternknoten des Template-Element mit Id 2.16.840.1.113883.10.22.4.10
Klassifikation	CDA Entry Level Template
Offen/Geschlossen	Offen (auch andere als die definierten Elemente sind erlaubt)
Assoziiert mit	Assoziiert mit 4 Konzepte Id Name Datensatz hl7ips-data​element-106  Observation Result  CEN/TC 251 prEN 17269 hl7ips-data​element-143  Date of observation  CEN/TC 251 prEN 17269 hl7ips-data​element-144  Observation Type  CEN/TC 251 prEN 17269 hl7ips-data​element-145  Value  CEN/TC 251 prEN 17269
Benutzt	Benutzt 2 Templates Benutzt als Name Version 2.16.840.1.113883.10.22.4.14 Inklusion IPS Body Author (STU1) DYNAMIC 2.16.840.1.113883.10.22.4.22 Containment IPS Comment Activity (STU1) DYNAMIC
Beziehung	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-
Beispiel	Beispiel <observation classCode="OBS" moodCode="EVN">   <templateId root="2.16.840.1.113883.10.22.4.10"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="..." codeSystem="1.2.3.999"/>  <statusCode/>  <effectiveTime>     <low value="20170721091742"/>  </effectiveTime>  <value xsi:type="PQ" value="136" unit="mmol/L"/>  <interpretationCode code="..." codeSystem="2.16.840.1.113883.5.83"/>  <methodCode code="..." codeSystem="1.2.3.999"/>  <targetSiteCode code="..." codeSystem="1.2.3.999"/>  <author>     <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->   </author>  <referenceRange>     <observationRange>       <value xsi:type="PQ" value=".." unit="..."/>      <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" displayName="Normal"/>    </observationRange>  </referenceRange>  <entryRelationship typeCode="COMP">     <!-- template 2.16.840.1.113883.10.22.4.22 'IPS Comment Activity' (dynamic) -->   </entryRelationship></observation>
Item DT Kard Konf Beschreibung Label hl7:observation   hl7ips-data​element-106  Observation Result  CEN/TC 251 prEN 17269 @classCode cs 1 … 1 F OBS @moodCode cs 1 … 1 F EVN hl7:templateId II 1 … 1 M @root uid 1 … 1 F 2.16.840.1.113883.10.22.4.10 hl7:id II 0 … * R hl7:code CD.IPS 1 … 1 M   hl7ips-data​element-144  Observation Type  CEN/TC 251 prEN 17269   CONF Der Wert von @code MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.11.22.38 IPS Results Observation (DYNAMIC) hl7:statusCode CS 1 … 1 M hl7:effectiveTime IVL_TS 1 … 1 R   hl7ips-data​element-143  Date of observation  CEN/TC 251 prEN 17269 Auswahl 1 … 1 Elemente in der Auswahl: hl7:value[@xsi:type='CE.IPS'] hl7:value[@xsi:type='PQ'] hl7:value[@xsi:type='IVL_PQ'] hl7:value[@xsi:type='ST'] hl7:value[@xsi:type='TS'] hl7:value[@xsi:type='RTO_QTY_QTY'] hl7:value CE.IPS 0 … 1 R wo [@xsi:type='CE.IPS']   hl7ips-data​element-145  Value  CEN/TC 251 prEN 17269   Beispiel Result code: code '201' from code system 2.16.840.1.113883.2.4.4.30.1045 <value xsi:type="CE" code="201" codeSystem="2.16.840.1.113883.2.4.4.30.1045" displayName="regular"/>   Beispiel Result code: code 'POS' from code system 2.16.840.1.113883.5.83 <value xsi:type="CE" code="POS" codeSystem="2.16.840.1.113883.5.83"/> hl7:value PQ 0 … 1 R wo [@xsi:type='PQ']   Constraint If Observation/value is a physical quantity (xsi:type="PQ"), the unit of measure SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 DYNAMIC   Beispiel Result physical quantity (data type PQ): 136 mmol per liter <value xsi:type="PQ" value="136" unit="mmol/L"/> hl7:value IVL_PQ 0 … 1 R wo [@xsi:type='IVL_PQ']   Beispiel Result interval of physical quantities (data type IVL_PQ): 150 - 400 Milliard per 10 exp 9 liter <value xsi:type="IVL_PQ">   <low value="150" unit="10+9/l"/>  <high value="400" unit="10+9/l"/></value> hl7:value ST 0 … 1 R wo [@xsi:type='ST']   Beispiel Result free text (data type ST) <value xsi:type="ST">This is a result as a free text</value> hl7:value TS 0 … 1 R wo [@xsi:type='TS']   Beispiel Result time stamp (data type TS): 6-Aug-2014 <value xsi:type="TS" value="20140806"/> hl7:value RTO_QTY_QTY 0 … 1 R wo [@xsi:type='RTO_QTY_QTY']   Beispiel Result ratio (data type RTO_QTY_QTY): 1/179 <value xsi:type="RTO_QTY_QTY">   <numerator xsi:type="INT" value="1"/>  <denominator xsi:type="INT" value="179"/></value> hl7:interpretationCode CE.IPS 0 … 1 R   CONF Der Wert von @code MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC) hl7:target​Site​Code CD.IPS (preferred) 0 … 1   CONF Der Wert von @code kommt vorzugsweise aus dem Value Set 2.16.840.1.113883.11.22.55 IPS Body Site (DYNAMIC) Eingefügt 0 … * R von 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC) hl7:author 0 … * R hl7:templateId II 1 … 1 M @root uid 1 … 1 F 2.16.840.1.113883.10.22.4.14 hl7:time TS.IPS.TZ 1 … 1 R hl7:assignedAuthor 1 … 1 M hl7:id II 1 … * R hl7:code 0 … 1 R Auswahl 0 … 1 Elemente in der Auswahl: hl7:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 0 … 1 C @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   Beispiel <name>   <given>John</given>  <family>Español Smith</family></name> hl7:family 1 … * R hl7:given 1 … * R hl7:assigned​Authoring​Device 0 … 1 C   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 cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:code CE 0 … 1 hl7:manufacturer​Model​Name SC 0 … 1 hl7:softwareName SC 0 … 1 hl7:represented​Organization 0 … 1 hl7:id II 0 … * hl7:name 0 … * hl7:telecom TEL 0 … * hl7:addr AD 0 … * hl7:referenceRange 0 … * R hl7:observationRange 1 … 1 M hl7:code CD NP hl7:value ANY 1 … 1 M hl7:interpretationCode CE 0 … 1 @code CONF 0 … 1 F N @codeSystem 0 … 1 F 2.16.840.1.113883.5.83 (Observation Interpretation) hl7:entryRelationship 0 … * Beinhaltet 2.16.840.1.113883.10.22.4.22 IPS Comment Activity (DYNAMIC) @typeCode cs 1 … 1 F COMP

1.2 Zusammenstellung aller Versionen dieses Templates

• 2017-03-02 (Unter Revision vor Publikation)