Submitted by jenna.stern on 2022-04-29
Analysis of clinical specimens to obtain information about the health of a patient.
Data Element |
Additional Information |
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Values/Results
Description
Documented findings of a tested specimen including structured and unstructured components..
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Applicable Vocabulary Standard(s) Applicable Standards
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Comment
Submitted by Riki Merrick APHL on 2021-09-29
Rename the element to Result Value; clarify its definition/use
This element should be called Result Value (to differentiate it from the performed test, which some also refer to as "result") (in v2 reported in OBX-5, in C-CDA and FHIR in observation.value). While the definition indicates this captures structured and unstructured data it is missing all the detail around how to address the different formats:- unstructured = narrative results use formated text, are human readable, but not easily usable for computers and harder to use in data comparison
- structured results fall into several categories and should be represented as follows:
- For qualitative tests:
- Coded to SNOMED CT drawn from organism hierarchy for organism names; drwan from qualifier hierachy for presence/absence findings and other ordinal results; drawn from clinical findings for pathology, microscopy, microbiology
- include the original text the coding was based on, if different from the description of the code
- For quantitative tests:
- include (in a separate field) the units of measure – coded to UCUM) - this should NOT be sent as a string in a single result field
- use a structured numeric datatype to allow support for ranges, ratios and smaller than/greater than statements
- For qualitative tests:
Submitted by Riki Merrick APHL on 2021-09-29
Addition to my comment above
The level 2 element https://www.healthit.gov/isa/taxonomy/term/2446/level-2 supports the renaming - these two elements need to be reconciled.Submitted by sabhyankar on 2020-10-23
Applicable stsandards for lab results
The Regenstrief LOINC team recommends adding the following Applicable Standard(s) text to the Values/Results row: “SNOMED CT for qualitative results, UCUM units of measure to accompany quantitative results.”Submitted by sabner on 2020-10-09
Submitted by hantran on 2022-09-30
CAP Comment on Values/Results Data Element
The College of American Pathologists (CAP) recommends replacing this data element with the Level 2 data element Laboratory Result Value.