Result panel with coded values of negative-positive

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 11/21/2013 and 3/5/2015 and 2/13/2020

  • SDWG: 3/12/2015. 2/27/2020

  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

C-CDA 2.1 Example:

  • 2.16.840.1.113883.10.20.22.2.3.1:2015-08-01
  • 2.16.840.1.113883.10.20.22.4.1:2015-08-01
  • 2.16.840.1.113883.10.20.22.4.119
  • 2.16.840.1.113883.10.20.22.4.2:2015-08-01

Reference to full CDA sample:

  • Results in empty CCD

Validation location

Comments

  • This is an example of how to encode positive and negative, which are common data types returned form lab equipment. While some technologies may represent this as a type of ST (string), it is logical and easily possible to encode this information using SNOMED-CT. This would allow structured examination of this information downstream as well as comparison to a structured reference range, as shown in the example.
  • Previously the examples task force approved this sample with the data type Coded Ordinal (CO) with the example name: Result panel with two ordinal values of negative-positive. The examples task force received feedback during implementation that CO is not commonly used, and CD is preferred. Updated the sample name to Result panel with coded values of negative-positive

Custodian

  • John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)
  • Brett Marquard brett@waveoneassociates.com (GitHub: brettmarquard)

Keywords

  • Results

Permalink

 

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">Chlamydia trachomatis and Neisseria gonorrhoeae rRNA panel -
						Urine by Probe and target amplification method at 10-22-2013 2:26p</th>
				</tr>
				<tr ID="LabResult3">
					<td>Chlamydia trachomatis rRNA [Presence] in Urine by Probe and target
						amplification method R</td>
					<td>Negative</td>
					<td>Normal</td>
					<td>Negative</td>
				</tr>
				<tr ID="LabResult4">
					<td>Neisseria gonorrhoeae rRNA [Presence] in Urine by Probe and target
						amplification method R</td>
					<td>Positive</td>
					<td>Abnormal</td>
					<td>Negative</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-b6cbcc4196fd"/>
			<code code="70161-5"
				displayName="Chlamydia trachomatis and Neisseria gonorrhoeae rRNA panel - Urine by NAA with probe detection"
				codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
			<statusCode code="completed"/>
			<effectiveTime>
				<low value="201310221426-0500"/>
				<high value="201310221426-0500"/>
			</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-07d10a3ef14d"/>
					<code code="42931-6"
						displayName="Chlamydia trachomatis rRNA [Presence] in Urine by NAA with probe detection"
						codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<text>
						<reference value="#LabResult3"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime value="201310221426-0500"/>
					<!-- Representing a result of an ordinal test (See LOINC axes) as negative in SNOMED-->
					<!-- Note, this example had type="CO" but feedback from implementation is this is not deployed, and CD is better -->
					<value xsi:type="CD" code="260385009" codeSystemName="SNOMED-CT"
						displayName="Negative" codeSystem="2.16.840.1.113883.6.96"/>
					<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83" displayName="Normal" />
					<referenceRange>
						<observationRange>
							<text>A negative value is a normal result</text>
							<value xsi:type="CD" code="260385009" codeSystemName="SNOMED-CT"
								displayName="Negative" 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" displayName="Normal" />
						</observationRange>
					</referenceRange>
				</observation>
			</component>
			<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="404bba0e-1c76-4265-afb5-1a57b55e128b"/>
					<code code="60256-5"
						displayName="Neisseria gonorrhoeae rRNA [Presence] in Urine by NAA with probe detection"
						codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<text>
						<reference value="#LabResult4"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime value="201310221426-0500"/>
					<!-- Representing a result of an ordinal test (See LOINC axes) as positive in SNOMED-->
					<value xsi:type="CD" code="10828004" codeSystemName="SNOMED-CT"
						displayName="Positive" codeSystem="2.16.840.1.113883.6.96"/>
					<interpretationCode code="A" codeSystem="2.16.840.1.113883.5.83" displayName="Abnormal" />
					<referenceRange>
						<observationRange>
							<text>A negative value is a normal result</text>
							<value xsi:type="CD" code="260385009" codeSystemName="SNOMED-CT"
								displayName="Negative" 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" displayName="Normal" />
						</observationRange>
					</referenceRange>
					<!-- Here is how additional reference ranges may be included-->
					<referenceRange>
						<observationRange>
							<text>A positive value is an abnormal result</text>
							<value xsi:type="CD" code="10828004" codeSystemName="SNOMED-CT"
								displayName="Positive" codeSystem="2.16.840.1.113883.6.96"/>
							<!-- This optional second interpretation code denotes that this reference range is for abnormal results. This is not the interpretation a specific patient value-->
							<interpretationCode code="A" codeSystem="2.16.840.1.113883.5.83" displayName="Abnormal" />
						</observationRange>
					</referenceRange>
				</observation>
			</component>
		</organizer>
	</entry>
</section>

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