Back To Index  <<  Back To Templates

pending Template  Result Observation

Template 2.16.840.1.113883.10.20.22.4.2 - ResultObservation
Id 2.16.840.1.113883.10.20.22.4.2
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Entry Level Template
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.2
Open/Closed Open (other than defined elements are allowed)
Description This clinical statement represents details of a lab, radiology, or other study performed on a patient. The result observation includes a statusCode to allow recording the status of an observation. If a Result Observation is not completed, the Result Organizer must include corresponding statusCode. “Pending” results (e.g., a test has been run but results have not been reported yet) should be represented as “active” ActStatus.
Used by / Uses
Used by / Uses 7 templates
Used by Template id as Name Version
2.16.840.1.113883.10.20.22.4.1 Containment ResultOrganizer Result Organizer 2013‑01‑31
2.16.840.1.113883.10.20.22.2.3 link ResultsSectionentriesoptional Results Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.1.3 link HistoryandPhysical History and Physical 2013‑01‑31
2.16.840.1.113883.10.20.22.1.4 link ConsultationNote Consultation Note 2013‑01‑31
2.16.840.1.113883.10.20.22.1.9 link ProgressNote Progress Note 2013‑01‑31
2.16.840.1.113883.10.20.22.2.3.1 link ResultsSectionentriesrequired Results Section (entries required) 2013‑01‑31
2.16.840.1.113883.10.20.22.1.2 link ContinuityofCareDocumentCCD Continuity of Care Document (CCD) 2013‑01‑31
Item DT Card Conf Description Label
cda:observation
(ResultObservation)
treetree @classCode
1 .. 1 F OBS
treetree @moodCode
1 .. 1 F EVN
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:7136) such that it conf‑7136
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.2
treetree cda:id
1 .. * M SHALL contain at least one [1..*] id (CONF:7137). conf‑7137
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:7133). conf‑7133
treetree cda:text
0 .. 1 R SHOULD contain zero or one [0..1] text (CONF:7138). conf‑7138
treeblank treetree cda:reference
0 .. 1 R The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15924).

This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)
conf‑15924
treeblank treeblank treetree @value
0 .. 1  
  Schematron assert role red error
  test count(cda:text/cda:reference[@value])=0 or starts-with(cda:text/cda:reference/@value, '#')
  Message This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)
treetree cda:statusCode
1 .. 1 M SHALL contain exactly one [1..1] statusCode (CONF:7134). conf‑7134
treetree cda:effectiveTime
1 .. 1 M SHALL contain exactly one [1..1] effectiveTime (CONF:7140).

Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards).
conf‑7140
treetree cda:value
1 .. 1 M SHALL contain exactly one [1..1] value (CONF:7143). conf‑7143
treetree cda:interpretationCode
0 .. * R SHOULD contain zero or more [0..*] interpretationCode (CONF:7147). conf‑7147
treetree cda:methodCode
CE 0 .. 1 MAY contain zero or one [0..1] methodCode (CONF:7148). conf‑7148
treetree cda:targetSiteCode
CD 0 .. 1 MAY contain zero or one [0..1] targetSiteCode (CONF:7153). conf‑7153
treetree cda:author
0 .. 1 MAY contain zero or one [0..1] author (CONF:7149). conf‑7149
treetree cda:referenceRange
0 .. * R SHOULD contain zero or more [0..*] referenceRange (CONF:7150). conf‑7150
treeblank treetree cda:observationRange
1 .. 1 M The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:7151). conf‑7151
treeblank treeblank treetree cda:code
This observationRange SHALL NOT contain [0..0] code (CONF:7152). conf‑7152
  Schematron assert role red error
  test not(cda:referenceRange/cda:observationRange/cda:code)
  Message This observationRange SHALL NOT contain [0..0] code (CONF:7152).