Release 5 Draft Ballot


Orders and Observations Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Patient, Practitioner

Raw XML (canonical form + also see XML Format Specification)

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General Specimen Example (id = "101")

<?xml version="1.0" encoding="UTF-8"?>

<Specimen xmlns="">
  <id value="101"/> 
  <!--   text>
    <status value="generated" />
    <div xmlns="">[Put rendering here]</div>
  </text>   -->
  <text> <status value="generated"/> <div xmlns=""><p> <b> Generated Narrative</b> </p> <p> <b> identifier</b> : id: 23234352356</p> <p> <b> accessionIdentifier</b> : id: X352356</p> <p> <b> status</b> : available</p> <p> <b> type</b> : <span> Venous blood specimen</span> </p> <p> <b> subject</b> : <a> Peter Patient. Generated Summary: Medical record number: 12345 (USUAL); active; Peter
           James Chalmers (OFFICIAL), Jim , Peter James Windsor (MAIDEN); , Phone: (03) 5555 6473,
           Phone: (03) 3410 5613, Phone: (03) 5555 8834; gender: male; birthDate: 1974-12-25; </a> </p> <p> <b> receivedTime</b> : Mar 4, 2011 7:03:00 AM</p> <p> <b> request</b> : <a> Generated Summary: status: completed; intent: order; <span> Diagnostics Procedure</span> ; <span> Computed tomography of head</span> </a> </p> <h3> Collections</h3> <table> <tr> <td> -</td> <td> <b> Collector</b> </td> <td> <b> Collected[x]</b> </td> <td> <b> Quantity</b> </td> <td> <b> Method</b> </td> <td> <b> BodySite</b> </td> </tr> <tr> <td> *</td> <td> <a> Generated Summary: id: 23; active; Adam Careful </a> </td> <td> May 30, 2011 6:15:00 AM</td> <td> 6 mL</td> <td> <span> Line, Venous</span> </td> <td> <span> Right median cubital vein</span> </td> </tr> </table> <h3> Containers</h3> <table> <tr> <td> -</td> <td> <b> Identifier</b> </td> <td> <b> Description</b> </td> <td> <b> Type</b> </td> <td> <b> Capacity</b> </td> <td> <b> SpecimenQuantity</b> </td> <td> <b> Additive[x]</b> </td> </tr> <tr> <td> *</td> <td> id: 48736-15394-75465</td> <td> Green Gel tube</td> <td> <span> Vacutainer</span> </td> <td> 10 mL</td> <td> 6 mL</td> <td> <a>  </a> <blockquote> <p> <b> code</b> : <span> Lithium/Li Heparin</span> </p> </blockquote> </td> </tr> </table> <p> <b> note</b> : Specimen is grossly lipemic</p> </div> </text> <contained> 
      <id value="hep"/> 
            <system value=""/> 
            <code value="HEPL"/> 
    <!--    a specimen identifier - e.g. assigned when the specimen was taken this is often not
     done    -->
    <system value=""/> 
    <value value="23234352356"/> 
    <system value=""/> 
    <value value="X352356"/> 
  <status value="available"/> 
   Type is a loosely defined field because there is such a lot of variation in how it
     is used.
   The principal variation is how much information that could be represented elsewhere
     is also
   represented here. For instance, here's some possible types:
     lithium heparin plasma   (+ .container.additive) (e.g. SNOMED CT 446272009)
     transfusion bag of blood (+ container.type)
     Peritoneal lavage        (+ collection.bodySite)
   If the type includes other fields, it would be normal not to populate the other fields

   Note that this practice is so widespread that it's pointless to try and stop it    -->
      <system value=""/> 
      <code value="122555007"/> 
      <display value="Venous blood specimen"/> 
    <reference value="Patient/example"/> 
    <display value="Peter Patient"/> 
  <receivedTime value="2011-03-04T07:03:00Z"/> 
    <!--    this points to the order that caused the sample to be drawn    -->
    <reference value="ServiceRequest/example"/> 
      <!--    in practice, collecter is almost always recorded    -->
      <reference value="Practitioner/example"/> 
    <!--    the time of collection is usually required. Usually a point in time, but can be a period
      (collectedPeriod) if it's a timed collection (e.g. a 24 hour urine)    -->
    <collectedDateTime value="2011-05-30T06:15:00Z"/> 
      <value value="6"/> 
      <unit value="mL"/> 
      <!--    e.g. full    -->
    <!--    method is usually implied by type    -->
        <system value=""/> 
        <code value="LNV"/> 
    <!--    bodysite is usually implied by type too its here to demonstrate its usage to indicating
     the draw site in this case   -->
        <system value=""/> 
        <code value="49852007"/> 
        <display value="Structure of median cubital vein (body structure)"/> 
      <text value="Right median cubital vein"/> 
      the container identifier is not the same as the specimen identifier
      usually, it is pre-printed/implanted etc.on the container prior to
      use. It might a RFID in the container, or it might be a UDI
    <!--    this is a serial number off the tube - there's no context such as a system    -->
    <value value="48736-15394-75465"/> 
  <description value="Green Gel tube"/> 
    <!--    again, this might easily be used to cover additives and capacity as well    -->
    <text value="Vacutainer"/> 
    <value value="10"/> 
    <unit value="mL"/> 
  <!--    if there's only one container, then this value is the same
     as .collection.quantity (usually). This is for when there is more
     than one container    -->
    <value value="6"/> 
    <unit value="mL"/> 
    <reference value="#hep"/> 
    <text value="Specimen is grossly lipemic"/> 

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.