Non-Normative Content The Normative content for these specifications may be found on the HL7, IHE, and HITSP web sites.

Results Section

The Results section contains the results of observations generated by laboratories, imaging procedures, and other procedures. The scope includes observations such as hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. The section often includes notable results such as abnormal values or relevant trends, and could contain 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 where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram.
Procedure results are typically generated by a clinician to provide more granular information about component observations made during  a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy.

The Results section contains the results of observations generated by laboratories, imaging procedures, and other procedures. The scope includes observations such as hematology, chemistry, serology, virology, toxicology, microbiology, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine, pathology, and procedure observations. The section often includes notable results such as abnormal values or relevant trends, and could contain 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 where a cardiologist reports the left ventricular ejection fraction based on the review of a cardiac echocardiogram. Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy.

Optional Entries

[Section: templateId 2.16.840.1.113883.10.20.22.2.3]

The following constraints apply to a Results Section in which entries are not required.

  1. SHALL contain exactly one [1..1] templateId ( CONF:7116, CONF:9136 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.3"
  2. SHALL contain exactly one [1..1] code (CONF:15431)/@code="30954-2" Relevant diagnostic tests and/or laboratory data (CodeSystem: 2.16.840.1.113883.6.1 LOINC) (CONF:15432)
  3. SHALL contain exactly one [1..1] title (CONF:8891)
  4. SHALL contain exactly one [1..1] text (CONF:7118)
  5. SHOULD contain zero or more [0..*] entry (CONF:7119, CONF:7120)
    1. Contains exactly one [1..1] Result Organizer (templateId: 2.16.840.1.113883.10.20.22.4.1)

Required Entries

The following constraints apply to a Results Section in which entries are required.

  1. SHALL contain exactly one [1..1] templateId ( CONF:7108, CONF:9137 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.3.1"
  2. SHALL conform to Results Section Entries Optional template (templateId: 2.16.840.1.113883.10.20.22.2.3)
  3. SHALL contain exactly one [1..1] code (CONF:15433)/@code="30954-2" Relevant diagnostic tests and/or laboratory data (CodeSystem: 2.16.840.1.113883.6.1 LOINC) (CONF:15434)
  4. SHALL contain exactly one [1..1] title (CONF:8892)
  5. SHALL contain exactly one [1..1] text (CONF:7111)
  6. SHALL contain at least one [1..*] entry (CONF:7112, CONF:7113)
    1. Contains exactly one [1..1] Result Organizer (templateId: 2.16.840.1.113883.10.20.22.4.1)