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pending Template  Hospital Discharge Studies Summary Section

Template 2.16.840.1.113883.10.20.22.2.16 - HospitalDischargeStudiesSummarySection
Id 2.16.840.1.113883.10.20.22.2.16
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Section Level Template
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.16
Open/Closed Open (other than defined elements are allowed)
Description This section records the results of observations generated by laboratories, imaging procedures, and other procedures. The scope includes hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. This section often includes notable results such as abnormal values or relevant trends, and could record all results for the period of time being documented. Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory. Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as where a cardiologist reports the left ventricular ejection fraction based on the review of an echocardiogram. Procedure results are typically generated by a clinician wanting to provide more granular information about component observations made during the performance of a procedure, such as when a gastroenterologist reports the size of a polyp observed during a colonoscopy. Note that there are discrepancies between CCD and the lab domain model, such as the effectiveTime in specimen collection.
Used by / Uses
Used by / Uses 1 template
Used by Template id as Name Version
2.16.840.1.113883.10.20.22.1.8 Containment DischargeSummary Discharge Summary 2013‑01‑31
Item DT Card Conf Description Label
cda:section
(HospitalDischargeStudiesSummarySection)
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:7910) such that it conf‑7910
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.2.16
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:15365). conf‑15365
treeblank treetree @code
1 .. 1 F 11493-4
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (LOINC)
treetree cda:title
1 .. 1 M SHALL contain exactly one [1..1] title (CONF:7912). conf‑7912
treetree cda:text
1 .. 1 M SHALL contain exactly one [1..1] text (CONF:7913). conf‑7913