Results Radiology with Image Narrative

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Example metadata last updated 2017-08-06 10:15:50.633000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • SDWG Reviewed: 3/10/2016
  • SDWG approved: 3/31/2016
  • SDWG C-CDA R2.1 Upgrade: 2/2/2017

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Comments:

  • This is an example of how to show a radiology result with narrative report in the results section. For the value, xsi-type equals ED (with reference) for encapsulated data.

Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub:jddamore)

Full sample: Results in empty CCD

Example: download example view on GitHub

<section>
	<templateId root="2.16.840.1.113883.10.20.22.2.3.1"/>
	<templateId root="2.16.840.1.113883.10.20.22.2.3.1" extension="2015-08-01"/>
	<!-- Results Section with Coded Entries Required-->
	<code code="30954-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Relevant diagnostic tests and/or laboratory data"/>
	<title>Results</title>
	<text>
		<table border="1">
			<thead>
				<tr>
					<th>Description</th>
					<th>Value / Unit</th>
					<th>Interpretation</th>
					<th>Reference Range</th>
				</tr>
			</thead>
			<tbody>
				<tr>
					<th colspan="4">Chest X-RAY 2 views</th>
				</tr>
				<tr>
					<th colspan="4">Performed on 02-25-2015 9:10a</th>
				</tr>
				<tr ID="Result1">
					<td>Chest X-Ray 2 Views</td>
					<td ID="Result1OriginalText" >
						The lungs are clear. The heart is enlarged with evidence of cardiomegaly.
						Pulmonary vasculature is normal. The aorta is mildly ectatic and tortuous.
						IMPRESSION: Cardiomegaly. No other acute abnormality. 
					</td>
					<td></td>
					<td></td>
				</tr>
				<tr>
					<th colspan="4">Electronically signed: Hermione Seaven, MD 02-25-2015 10:32a</th>
				</tr>
			</tbody>
		</table>
	</text>
	<entry>
		<organizer classCode="CLUSTER" moodCode="EVN">
			<!-- Selected CLUSTER since not a set of tests -->
			<templateId root="2.16.840.1.113883.10.20.22.4.1"/>
			<templateId root="2.16.840.1.113883.10.20.22.4.1" extension="2015-08-01"/>
			<!-- Results Organizer -->
			<id root="e1aa44dd-6f39-4f5c-b267-897c3821b563"/>
			<code code="71020" displayName="Chest X-Ray 2 Views" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT"/>
			<statusCode code="completed"/>
			<!-- an organizer/effectiveTime value="20150225091059-0500" could be used but is not required -->
			<component>
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.2"/>
					<templateId root="2.16.840.1.113883.10.20.22.4.2" extension="2015-08-01"/>
					<!-- Results Observation -->
					<id root="e1aa44dd-6f39-2f5c-b267-897c3824b563"/>
					<code code="36643-5" displayName="Chest X-ray 2 Views" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC">
						<!-- a translation code may be helpful and used by some EHRs to denote that this is a textual response of result impression -->
					</code>
					<text>
						<reference value="#Result1"/>
					</text>
					<statusCode code="completed"/>
					<!-- This is the timestamp of biologically relevance (i.e. when chest x-ray was performed), aligning with HL7 v3 modeling. -->
					<effectiveTime value="20150225091059-0500"/>
					<value xsi:type="ED">
						<reference value="#Result1OriginalText" />
					</value>
					<interpretationCode nullFlavor="NI"/>
					<author>
						<!-- This is the timestamp of when the author (i.e. the radiologist) interepreted the chest x-ray-->
						<time value="20150225103206-0500"/>
						<assignedAuthor>
							<id extension="66666" root="2.16.840.1.113883.4.6"/>
							<code code="111NR0200X" codeSystem="2.16.840.1.113883.6.101" codeSystemName="NUCC" displayName="Radiology"/>
							<addr>
								<streetAddressLine>6666 StreetName St.</streetAddressLine>
								<city>Silver Spring</city>
								<state>MD</state>
								<postalCode>20901</postalCode>
								<country>US</country>
							</addr>
							<telecom value="tel:+1(301)666-6666" use="WP"/>
							<assignedPerson>
								<name>
									<given>Hermione</given>
									<family>Seaven</family>
									<suffix>MD</suffix>
								</name>
							</assignedPerson>
						</assignedAuthor>
					</author>
				</observation>
			</component>
		</organizer>
	</entry>
</section>
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