Result COVID Positive

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Approval Status

  • Approval Status: Approved
  • Examples Task Force: 4/16/2020
  • Structured Documents: 5/28/2020

Template Examples (for inclusion in C-CDA):

  • Results Section 2.16.840.1.113883.10.20.22.2.3.1:2015-08-01
  • Results Organizer 2.16.840.1.113883.10.20.22.4.1:2015-08-01
  • Results Observation 2.16.840.1.113883.10.20.22.4.2:2015-08-01

Reference to full CDA sample

  • N/A

Validation location

  • HL7 Schematron (Diameter Health hosted) March 2020

Comments:

  • This is an example of a positive COVID result using one potential LOINC code. Please note that LOINC information may change as this was an urgent release. Other possible LOINC codes are noted in comments of the example

Custodian:

Keywords:

  • COVID, coronavirus, result, positive, negative

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Example: download example view on GitHub

<section>
    <!-- Results Section with Coded Entries Required-->
    <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"/>
    <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">SARS coronavirus 2 RNA panel</th>
                </tr>
                <tr ID="LabResult3">
                    <td>SARS coronavirus 2 RNA</td>
                    <td>Detected</td>
                    <td>Abnormal</td>
                    <td>Reference (Normal) for this test is not detected</td>
                </tr>
            </tbody>
        </table>
    </text>
    <entry>
        <organizer classCode="BATTERY" moodCode="EVN">
            <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"/>
            <id root="b5684bf0-eb6f-46dd-9f2e-b6cbcc4155fd"/>
            <!-- There are LOINC panel codes for a COVID as well as a CPT code-->
            <!-- Panel codes include: 94306-8, 94503-0, 94504-8, 94531-1 -->
            <!-- Please note that these are pre-release LOINC codes and codes may change over time -->
            <code code="94531-1" displayName="SARS coronavirus 2 RNA panel" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
            <!-- Alternatively CPT codes may be used in the panel as what was ordered -->
            <!-- <code code="87635" displayName="Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT"/> -->
            <statusCode code="completed"/>
            <effectiveTime>
                <low value="202003221426-0500"/>
                <high value="202003221426-0500"/>
            </effectiveTime>
            <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"/>
                    <id root="5a6be91a-32d5-4d24-a8bd-07d10a33414d"/>
                    <!-- This is a LOINC code uses respiratory sample which would include nasal pharynx swab. Other codes that could be used in different circumstances include -->
                    <!-- All potential codes for different sample sites or methods include: 94306-8, 94307-6, 94308-4, 94309-2, 94310-0, 94311-8, 94312-6, 94313-4, 94314-2, 94315-9, 94316-7, 94499-1, 94500-6
                        <!-- 94501-4, 94502-2, 94503-0, 94504-8, 94505-5, 94506-3, 94507-1, 94508-9, 94509-7, 94510-5, 94511-3, 94531-1, 94532-9, 94533-7, 94534-5, 94547-7	-->
                    <!-- You can check LOINC code detail by using their open API, such as https://loinc.org/94500-6/ -->
                    <!-- Please note that these are pre-release LOINC codes and codes may change over time -->
                    <code code="94500-6" displayName="SARS coronavirus 2 RNA" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
                    <text>
                        <reference value="#LabResult3"/>
                    </text>
                    <statusCode code="completed"/>
                    <effectiveTime value="202003221426-0500"/>
                    <!-- Since this is a pre-release code there is not an established answer list and this may vary -->
                    <value xsi:type="CD" code="260373001" codeSystemName="SNOMED-CT" displayName="Detected" codeSystem="2.16.840.1.113883.6.96"/>
                    <interpretationCode code="A" codeSystem="2.16.840.1.113883.5.83"/>
                    <referenceRange>
                        <observationRange>
                            <text>Reference (Normal) for this test is not detected</text>
                            <value xsi:type="CD" code="260415000" codeSystemName="SNOMED-CT" displayName="Not Detected" codeSystem="2.16.840.1.113883.6.96"/>
                            <!-- This interpretation code denotes that this reference range is for normal results. This is not the interpretation a specific patient value-->
                            <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
                        </observationRange>
                    </referenceRange>
                </observation>
            </component>
        </organizer>
    </entry>
</section>
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