Results

Section Code

LOINC: 30954-2 (Relevant diagnostic tests/laboratory data)

Description

The results section describes relevant diagnostic test procedures the patient received in the past.

CDA Level

Level 2 or Level 3

Template IDs

Level / Spec

Template ID

Standards Reference

3 / CCD

2.16.840.1.113883.10.20.1.14

CCD 3.13

2 / IHE

1.3.6.1.4.1.19376.1.5.3.1.3.27

IHE PCC TF-2: 6.3.3.5.1

3 / IHE

1.3.6.1.4.1.19376.1.5.3.1.3.28

IHE PCC TF-2: 6.3.3.5.2

Expected Entries / Sub-Sections

Entry

Template ID

Reference

Results Organizer

2.16.840.1.113883.10.20.1.32

Procedure

1.3.6.1.4.1.19376.1.5.3.1.4.19

3.4.2.18

External References

1.3.6.1.4.1.19376.1.5.3.1.4.4

3.4.2.8

Simple Observation

2.16.840.1.113883.10.20.1.31
1.3.6.1.4.1.19376.1.5.3.1.4.13

3.4.2.20

OpenSHR Implementation Notes

Data Model

Obs

Code File

CodedResultsSectionProcessor.java

Additional Constraints

• None

Notes

The "results organizer" entry and CCD template for Simple Observation (in the CCD documentation Results Observation) are only used by the on-demand documents generator and are not supported in CDA import. The SHR will consume results with Procedures, External References and Simple Observations only.

Specification

<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<!-- IHE PCC Results -->
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.27"/>
<!-- IHE PCC Coded Results -->
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.28"/>
<!-- Section Code -->
<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
displayName="Relevant diagnostic tests/laboratory data"/>
<title language="en-US">Results</title>
<!-- 1..1 Text as described in the general implementation notes -->
<text mediaType="text/x-hl7-text+xml">
...
</text>
<!-- 0..n Procedures indicating the past procedures -->
<entry typeCode="COMP" contextConductionInd="true">
<procedure moodCode="EVN">
...
</procedure>
</entry>
<!-- 0..n Observation indicating results of past procedures -->
<entry typeCode="COMP" contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
...
</observation>
</entry>
<!-- 0..n Act entries indicating external references -->
<entry typeCode="COMP" contextConductionInd="true">
<act moodCode="EVN">
...
</act>
</entry>
</section>
</component>