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draft Template  Hospital Discharge Studies Summary Section

Id 2.16.840.1.113883.10.20.22.2.16
ref
ccda-
Effective Date 2015‑08‑13
Status draft Draft Version Label 2.1
Name HospitalDischargeStudiesSummarySection Display Name Hospital Discharge Studies Summary Section
Description
This section records the results of observations generated by laboratories, imaging procedures, and other procedures. The scope includes hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. This section often includes notable results such as abnormal values or relevant trends, and could record all results for the period of time being documented. Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory. Imaging results are typically generated by a clinician reviewing the output of an imaging procedure, such as when a cardiologist reports the left ventricular ejection fraction based on the review of an echocardiogram. Procedure results are typically generated by a clinician wanting to provide more granular information about component observations made during the performance of a procedure, such as when a gastroenterologist reports the size of a polyp observed during a colonoscopy. Note that there are discrepancies between CCD and the lab domain model, such as the effectiveTime in specimen collection.
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.16
Classification CDA Section Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 0 templates
Used by as Name Version
2.16.840.1.113883.2.51.10.12 Containment draft XeH Hospital Discharge Report (0.1) 2021‑09‑10 14:49:32
Relationship Specialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
Item DT Card Conf Description Label
cda:section
(Hosdotsion)
cda:templateId
II 1 … 1 M SHALL contain exactly one [1..1] templateId (CONF:81-7910) such that it CONFdots7910
@root
1 … 1 F 2.16.840.1.113883.10.20.22.2.16 CONFdots0398
  SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.16" (CONF:81-10398).
cda:code
CE 1 … 1 M SHALL contain exactly one [1..1] code (CONF:81-15365). CONFdots5365
@code
CONF 1 … 1 F 11493-4
@codeSystem
1 … 1 F 2.16.840.1.113883.6.1 (LOINC)
cda:title
ST 1 … 1 SHALL contain exactly one [1..1] title (CONF:81-7912). CONFdots7912
cda:text
SD.TEXT 1 … 1 R SHALL contain exactly one [1..1] text (CONF:81-7913). CONFdots7913