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Result

Reference:2.2.2.15
Definition:Within a CDA document, the following information maps to the HITSP/C154 Data Dictionary. See the HL7 Continuity of Care Document Section 3.13 for constraints applicable to these data elements. This module contains current and relevant historical result observations for the patient. The scope of "observations" is broad with the exception of "vital signs" which are contained in the Vital Signs sections (see Section 2.2.2.14 above). The Results section is intended as a summary and not as an official, legally sanctioned report. For example, regulatory requirements for lab reports are not necessarily supported in the following Data Element Definitions. In the case of lab reports, the official report is supported in HITSP/C37 Laboratory Report Document Using IHE XD* Lab.
OID:2.16.840.1.113883.3.88.11.83.15.1
CDA Data Location HITSP Data Element Identifier and Name O/R Additional Specification
cda:observation[cda:templateId/@root = '2.16.840.1.113883.10.20.1.31'] Result Event Entry See Below23
cda:id 15.01 - Result ID R/Y
cda:effectiveTime 15.02 - Result Date/Time R/N
cda:code/@code 15.03 - Result Type R/N 2.2.2.15.2
cda:statusCode 15.04 - Result Status R/N
cda:value 15.05 - Result Value C/N 2.2.2.15.3
cda:interpretationCode/@code 15.06 - Result Interpretation O/N
cda:referenceRange 15.07 - Result Reference Range O/Y

Optionality Legend: “R” for Required, “R2” for Required if known, “O” for Optional and Repeat = “Y” for Yes or “N” for No

Result Example

<!-- These examples assume the default namespace is 'urn:hl7-org:v3' -->
<observation classCode='OBS' moodCode='EVN'>
<templateId root='2.16.840.1.113883.10.20.1.31'/>
<templateId root='2.16.840.1.113883.3.88.11.83.15'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<code code='...' displayName='...' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<effectiveTime low value='...'/>
<statusCode value='N'/>
<value xsi:type="PQ" value="100" unit="g/dl"/>
<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
<referenceRange>
<observationRange>
<text>M 13-18 g/dl; F 12-16 g/dl</text>
</observationRange>
</referenceRange>
</observation>

Section ID Constraint ID Definition
2.2.2.15.1 Results Module Constraints Not Provided
C83-[DE-15-CDA-1] A CDA Document SHALL declare conformance for the Results module by including a <templateID> element with the root attribute set to the value 2.16.840.1.113883.3.88.11.83.15.1
C83-[DE-15-CDA-2] Results data elements reporting specific events SHALL declare conformance to the IHE Simple Observation entry by including a <templateID> element with the root attribute set to the value 1.3.6.1.4.1.19376.1.5.3.1.4.13
C83-[DE-15-CDA-3] Results data elements reporting specific events SHALL declare conformance to the CCD Result entry by including a <templateID> element with the root attribute set to the value 2.16.840.1.113883.10.20.1.3
2.2.2.15.2 Result Type Constraints Not Provided
C154-[DE-15.03-1] Result Type SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96)
C154-[DE-15.03-2] Result Type for laboratory results SHOULD be coded as specified in HITSP/C80 Section 2.2.3.6.1 Laboratory Observations.
2.2.2.15.3 Result Value Constraints The Result value records the desired result in a goal or recorded event, and will not present when recording an intent, request or proposal to measure a result.
C83-[DE-15.05-CDA-1] Result Value SHALL be present when the observation/@moodCode is EVN or GOL, and SHALL NOT be present when observation/@moodCode is INT or PRP.
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