Материал: part20

10.1.1 code and @negationInd​

TheObservationcodeelementhasanassociatedConceptDomainObservationType.ArepresentativebindingforthisConceptDomain​ is to the value (ASSERTION, actcode[2.16.840.1.113883.5.4], "Assertion"), providing an assertion of a finding concept in the value​ element.​

- Standard -​

The Observation may have @negationInd attribute "true", which together with the code "ASSERTION" indicates that the finding was​ not observed, e.g., to represent "No finding of stroke".​

Note​

This is the pattern used in Consolidated CDA for negative findings.​

10.1.2 text/reference and Related Narrative Block Markup​

The Observation entry SHOULD include a text/reference element, whose value attribute (not to be confused with the value element​ oftheObservationclass)SHALLbeginwitha'#'andSHALLpointtoitscorrespondingnarrativeintheparentsection(usingtheapproach​ defined in CDA Release 2, section 4.3.5.1). See Section 9.1.1.1.​

10.1.3 interpretationCode and translation For Actionable Findings​

When an observation is unexpected or "actionable" (one type of which is denoted a "critical finding"), it may be flagged using the in-​ terpretationCode.ForveryabnormalfindingstheinterpretationCodeelementSHALLbesetto(AA,ObservationInterpretation,"abnormal​ alert"). Unexpected normal findings, e.g., no findings of disease when patient treatment had been planned on the presumption of​ disease, may also be flagged using interpretationCode (N, ObservationInterpretation, "normal").​

The translation element of the interpretationCode may be used to provide a further classification as defined in a regionallyor profes-​ sionally-specified value set. This template identifies an optional value set for the ACR Actionable Finding categories 1, 2, and 3, as​ defined by: Larson PA, et al. J Am Coll Radiol 2014; published online. DOI 10.1016/j.jacr.2013.12.016.​

The narrative text associated with the actionable finding SHOULD be highlighted using styleCode Bold. See Section 9.5.1 and Sec-​ tion 9.1.1.1.​

Actionable findings that require a specific follow-up action or procedure SHOULD be referenced from a recommendation in the 9.8.11​ Recommendation section.​

Communication of actionable findings SHOULD be documented in the 9.8.10 Communication of Actionable Findings section.​

10.1.4 targetSiteCode​

Each observation needs to fully specify its site/location.​

COND: If the observation site is not pre-coordinated in the observation/code or observation/value, it SHALL be specified in the obser-​ vation/targetSiteCode.​

COND: The qualifier element for laterality SHALL be present if the targetSiteCode represents a paired body part and laterality is not​ pre-coordinated in the targetSiteCode.​

Note that inclusion in a labeled subsection (see Section 9.8.9) does not imply a finding site for the observation from the title. The title​ is not semantically part of the post-coordination.​

10.1.5 entryRelationship/@typeCode=SUBJ/observation - Coded​

TheCodedObservationentryMAYincludeanactRelationshipoftypeSUBJ(hassubject)toasubsidiaryCodedObservation(recursively​ invoking this same template). This allows the constructions of complex clinical statements.​

Example 10.1-1. Coded observation example​

<text>

...

<content ID="fnd-1"> ...finding of a right hilar mass (abnormal - class 1) ...</content> </text>

...

<entry>

<observation classCode="OBS" moodCode="EVN">

- Standard -​

<templateId root="2.16.840.1.113883.10.20.6.2.13"/> <id root="1.2.840.10213.2.62.7044779.114265201"/>

<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" codeSystemName="actCode"

displayName="Assertion"/> <text><reference value="#fnd-1"/></text> <statusCode code="completed"/> <effectiveTime value="20140914171504+0500"/> <value xsi:type="CD" code="309530007"

codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Hilar mass"/>

<interpretationCode code = "AA" codeSystem="2.16.840.1.113883.5.83" codeSystemName="ObservationInterpretation" displayName="Abnormal Alert">

<translation code="RID49480" codeSystem="2.16.840.1.113883.6.256" codeSystemName="RADLEX"

displayName="ACR Category 1 Actionable Finding"/> </interpretationCode>

<!-- although "hilar mass" is by definition in the lung, the observation.value does not describe right or left lung, so targetSite is required -->

<targetSiteCode code="3341006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="right lung">

</targetSiteCode>

<!-- entryRelationship elements referring to SOP Instance Observations or Quantity Measurement Observations may appear here -->

</observation>

</entry>

10.2 Procedural Medication​

- Standard -​

10.2.1 Business Name Alias​

This template defines a primary scoping business name "ProceduralMedication" and an alias "Contrast". This allows production logic​ to use either term, although the structure is identical.​

10.2.2 text/reference and Related Narrative Block Markup​

The substanceAdministration entry SHOULD include a text/reference element, whose value attribute SHALL begin with a '#' and​ SHALL point to its corresponding narrative in the parent section (using the approach defined in CDA Release 2, section 4.3.5.1). See​ Section 9.1.1.1.​

10.2.3 doseQuantity​

•​Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then​ doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol​ 25mg tablet").​

- Standard -​

•​Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is simply "metoprolol"), then doseQuantity​ must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration.​

Example 10.2-1. Procedural Medication activity example​

<substanceAdministration classCode="SBADM" moodCode="EVN"> <templateId root="1.2.840.10008.9.13"/>

<id root="cdbd33f0-6cde-11db-9fe1-0800200c9a66"/> <text>

<reference value="#med1"/> </text>

<statusCode code="completed"/>

<routeCode code="47625008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="intravenous route"/>

<doseQuantity value="100" unit="ml"/> <consumable>

<manufacturedProduct classCode="MANU">

<templateId root="2.16.840.1.113883.10.20.22.4.23"/> <id/>

<manufacturedMaterial> <code code="412372002"

codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Meglumine Diatrizoate">

<originalText>

<reference value="#manmat1"/> </originalText>

<translation code="3320"

codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="Diatrizoate Meglumine"/>

</code>

</manufacturedMaterial>

</manufacturedProduct>

</consumable>

</substanceAdministration>

10.3 observationMedia​

- Standard -​