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.
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