ResultObservation

Result Observation

draftC-CDA Templates4.0.0logical11 key elements

This template represents the results of a laboratory, radiology, or other study performed on a patient.

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.

If code contains a valid non-null LOINC then the xsi:type value SHOULD match the LOINC Scale Part based on the table below:

| LOINC Scale Part | Value xsi:type | | -------- | ------- | | Qn - Quantitative | INT, IVL_INT, MO, IVL_MO, REAL, IVL_REAL, PQ, IVL_PQ, RTO, TS, IVL_TS | | Ord - Ordinal | CD | | Nom - Nominal | CD | | Nar - Narrative | ED, ST | | OrdQn - Quantitative or Ordinal | CD, INT, IVL_INT, MO, IVL_MO, REAL, IVL_REAL, PQ, IVL_PQ, RTO, TS, IVL_TS | | Multi - Multi | ED | | Doc - Document | ED |

The Result Observation template is a versatile template designed to represent any type of finding resulting from various types of tests. Value set bindings for Observation.code have been created to support implementers, covering three categories: 1) Common Laboratory Tests, 2) Radiology Tests, and 3) Clinical Tests. If a suitable code is not available within these value sets, first use another LOINC code. If no LOINC code is appropriate, a local code may be used.

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/cda/us/ccda/StructureDefinition/ResultObservation
ID
ResultObservation
Type
Base Definition
Observation
Derivation
constraint
Mandatory and Must-Support Elements

Elements with cardinality > 0 or marked as Must Support (S)

PathCard.TypeFlagsDescription
templateId
1+
:result-obs1..1
1+
templateId.root
1+
templateId.extension
1+
id
1+
statusCode
1+
𝗨𝗦𝗖𝗗𝗜: Result Status
statusCode.code
1+
effectiveTime
1+
Represents the clinically relevant time of the measurement (e.g., the time a blood pressure reading is obtained, the time the blood sample was obtained for a chemistry test).
value1..1
1+
𝗨𝗦𝗖𝗗𝗜: Values/Results - Value can be any type, but certain types have additional rules.
value.unit
1+
𝗨𝗦𝗖𝗗𝗜: Result Unit of Measure
referenceRange.observationRange.value
1+
When the value is a quantity, then the unit SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive.