Template 2.16.840.1.113883. Results Section (entries required)


Template 2.16.840.1.113883. - ResultsSectionentriesrequired
Id 2.16.840.1.113883.
Classification cdasectionlevel
Context Parent nodes of template element with id 2.16.840.1.113883.
Label conf‑606
Version valid from 2012‑01‑12 status draft
Description The Results section contains the results of observations generated by laboratories, imaging procedures, and other procedures. The scope includes observations such as hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. The section often includes notable results such as abnormal values or relevant trends, and could contain 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 a cardiac echocardiogram.

Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy.
Item DT Card Conf Desc Label
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1..1 F Relevant diagnostic tests and/or laboratory data
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