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Result Observation

[Observation: templateId 2.16.840.1.113883.10.20.22.4.2]

This clinical statement represents details of a lab, radiology, or other study performed on a patient.


The result observation includes a statusCode to allow recording the status of an observation. If a Results Observation is not completed, the Result Organizer must include corresponding statusCode. "Pending" results (e.g., a test has been run but results have not been reported yet) should be represented as "active" ActStatus.

  1. SHALL contain exactly one [1..1] templateId ( CONF:9138 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.2"
  2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:7130)
  3. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: 2.16.840.1.113883.5.1001 HL7ActMood) (CONF:7131)
  4. SHALL contain at least one [1..*] id (CONF:7137)
  5. SHALL contain exactly one [1..1] code (CONF:7133)
  6. SHOULD contain zero or one [0..1] text (CONF:7138)
    1. text, if present, SHOULD contain zero or one [0..1] reference (CONF:15924)
      1. reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15925)
      2. This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15926)
  7. SHALL contain exactly one [1..1] statusCode (CONF:7134), where the @code SHALL be selected from ValueSet Result Status 2.16.840.1.113883.11.20.9.39 STATIC 2012-04-27 (CONF:14849)
  8. SHALL contain exactly one [1..1] effectiveTime (CONF:7140, CONF:7141)
    • Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) CONF:16838

  9. SHALL contain exactly one [1..1] value (CONF:7143)
  10. SHOULD contain zero or more [0..*] interpretationCode (CONF:7147)
  11. MAY contain zero or one [0..1] methodCode (CONF:7148)
  12. MAY contain zero or one [0..1] targetSiteCode with data type CE (CONF:7153)
  13. The value for 'code' in a result observation SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96) Laboratory results SHOULD be from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or other constrained terminology named by the US Department of Health and Human Services Office of National Coordinator or other federal agency. Local and/or regional codes for laboratory results are allowed. The Local and/or regional codes SHOULD be sent in the translation element. (CONF:7166)
  14. SHOULD contain zero or more [0..*] referenceRange. Such referenceRanges, if present, SHALL contain exactly one [1..1] observationRange. This observationRange SHALL NOT contain [0..0] code (CONF:7152)
  15. MAY contain zero or one [0..1] author (CONF:7149)

Result Observation example

<observation xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3">
  <id root="MDHT" extension="1651600191"/>
  <code code="2032256340"/>
  <text>Text Value</text>
  <statusCode code="completed"/>
  <effectiveTime>
    <low value="2013"/>
    <high value="2013"/>
  </effectiveTime>
  <interpretationCode code="590713028"/>
  <methodCode code="485303255"/>
  <targetSiteCode xsi:type="CE" code="587140140"/>
</observation>