Observation Reporting
This chapter describes the transaction set required for sending structured
patient oriented clinical data from one computer system to another. A common
use of these transaction sets will be to transmit observations and results of
diagnostic studies from the producing system (e.g., clinical laboratory system,
EKG system) (the filler), to the ordering system (e.g., HIS order entry,
physician's office system) (the placer). However, the transaction set is not
limited to such transactions. Observations can be sent from producing systems
to archival medical record systems ( not necessarily the order placer) and from
such medical record systems to other systems that were not part of the ordering
loop, e.g., an office practice system of the referring physician for inpatient
test results ordered by an inpatient surgeon.
These transaction sets permit the transmission of any kind of clinical
observations including (but not limited to) clinical laboratory results, the
results of imaging studies (excluding the image), EKG pulmonary function
studies, measures of patient status and condition, vital signs, Intake and
output, severity and/or frequency of symptoms, drug allergies, problem lists,
diagnostic lists, physician and nursing history, physicals, progress notes,
operative notes and so on. These transaction sets carry information that is
reported as text, numeric or categorical values. These messages do not carry
the images or tracings themselves. (See ACR NEMA Publication 300-1988
Digital Imaging and Communications Standard, for image standards, and ASTM
E1467.91 Standard specification for transferring digital neurophysiological
data between independent computer systems, for transmitting EEG and EMG
tracings.)
An observation can be one of many data types. The main ones are text, numbers
and codes. This provides the flexibility needed to transmit observations that
are recorded as continuous values (e.g., glucose, diastolic blood pressure), as
categorical values, e.g., patient position (sitting, reclining or standing),
VDRL (reactive, weakly reactive or nonreactive), or as text. An entire History
and Physical could be transmitted as an observation whose value is one large
chunk of formatted text.
This chapter provides mechanisms for transmitting structured,
record-oriented reports. This means that individual observations are
transmitted as separate logical entities (objects), and within this entity,
separate fields are defined for identifying the observation, its values, its
units, normal ranges, etc, such that the receiving system can "understand,"
reorganize and/or react to the contents of these messages. Structured reports
are to be distinguished from text oriented reports which can also be
transmitted via HL7 using the UDM message described in Chapter 2. The latter
are ASCII images of nonstandard printed reports intended for display to humans.
For practical purposes their contents are not "understandable" to the computer.
Observations may be transmitted in a solicited (in response to a query) or
unsolicited mode. In the solicited mode, a user requests a set of observations
according to criteria transmitted by the user. The sending system responds with
existing data to satisfy the query (subject to access controls). Queries do
not elicit new observations by the target system, they simply retrieve "old"
observations. (See Chapter 2 for full discussion of the query transmission.)
The unsolicited mode is used primarily to transmit the values of new
observations. It is the mode used by producing services to return the values of
observations requested by an ordering system. A laboratory system, for
example, would usually send the results of an AM electrolytes to the ordering
HIS via the unsolicited mode. An intensive care system would send the blood
pressures to the same HIS by the same mode. Calling such transactions
unsolicited may sound like a misnomer, but is not. The placing service
solicits the producing service to make the observation. It could also (through
a query) solicit the value of that observation after it has been made.
However, such an approach would demand continuous polling of the producing
system until the result was produced. Using the unsolicited mode, the
producing service returns the value of an observation as soon as it is
available. The unsolicited mode can also be used to transmit new results to a
system (e.g. an archival medical record system) that did not order the
observation. The transactions that define these modes are more fully described
in Section 7.2.
Observations are usually ordered and reported as sets (batteries) of many
separate observations. Physicians order electrolytes (consisting of sodium,
potassium, chloride, bicarbonate) or vitals (consisting of diastolic blood
pressure, systolic blood pressure, pulse, and temperature). Moreover, tests
that we may think of as single entity, e.g., cardiac echo, usually yield
multiple separate measurements, e.g. left ventricular diameter, left atrial
diameter, etc. Moreover, observations that are usually reported as text (e.g.
the review of systems from the history and physical) can also be considered a
set of separately analyzable units (e.g. cardiac history, pulmonary history,
genito-urinary history, etc). We strongly suggest that all "text" clinical
reports be broken down into such separate analyzable entities and that these
individual entities be transmitted as separate OBX segments. Because many
attributes of a set of observations taken at one time will be identical, one
OBR segment serves as a header for the report and carries the information that
applies to all of the individual observations in the set. In the case of
ordered observations, the OBR segment is a "turn-around document" like the
manual request forms it replaces. It carries information about the order to
the producing service; a copy of the OBR with additional fields completed is
returned with the observations to the requesting service.
Not all observations are preceded by an order. However, all observations
whether explicitly ordered or initiated without an order are reported with an
OBR segment as the report header.
The major segments (OBR, OBX) defined in this chapter, their fields, and the
code tables have been defined in collaboration with ASTM E31.11 with the goal
of keeping HL7 observation transmission the same as ASTM E1238 in pursuit of
the goals of ANSI HISPP and the Message Standards Developers Subcommittee.
(Many sections of this chapter have been taken with permission directly from
the E1238-91 document and vice versa in pursuit of those goals).
The OBR segment provides information that applies to all of the observations
that follow. It includes a field that identifies a particular battery (or
panel or set) of observations (e.g., electrolytes, vital signs or Admission
H&P). For simplicity we will refer to the observation set as the battery.
The battery usually corresponds to the entity that is ordered or performed as a
unit. (In the case of a query, observation sets may be a more arbitrary
collection of observations.) The OBX segment provides information about a
single observation, and it includes a field that identifies that single
observation (e.g., potassium, diastolic blood pressure or admission diagnosis).
Both of these fields assume master tables that define coding systems (the
universe of valid identifying codes) for batteries and observations,
respectively. These tables will usually be part of the producing and sending
services application and (usually) include many other useful pieces of
information about the observation or battery. HL7 and ASTM are currently
developing a segment for transmitting such master file information between
systems that produce and systems that use clinical information.
This standard does not require the use of a particular coding system to
identify either batteries or single observations. These are often defined
locally, within a single institution or consortium of institutions. However,
they may be based on an externally defined coding standard. Chapter 2's
discussion of CE data types indicates how to identify the battery and
observation coding system. We encourage the use of universal coding systems
when they are available (see Figure 2-2 of Chapter 2) to facilitate the
exchange of clinical information between organizations (e.g., from physician's
office, to hospital or nursing home and back). Moreover, we provide
suggestions about constructing codes for observations (such as the components
of the history and physical, EKG, cardiac cath, etc.) that are often not
included in either "universal" or local procedure coding systems. These are
given in Appendix A of Chapter 7. Most of these codes are presented as
extensions to the CPT4 code system. But the same construction rules could be
used to extend any procedure code system.
Many parts of this document (the discussion and tables defining units, the
discussion of the rules of mapping observations to OBX segments, many of the
examples at the end of the chapter, and Appendix 7.A), have been copied (with
permission) from ASTM E1238-91.
As is true throughout this standard, the emphasis should be on the abstract
messages, defined without regard to the encoding rules. The example messages,
however, are based upon the HL7 encoding rules.
placer: Person or service that requests (places order for) an
observation battery, e.g., the physician, the practice, clinic, or ward
service, that orders a lab test, xray, vital signs, etc. The meaning is
synonymous with, and used interchangably with, requestor. See ORC-3-placer
number, Section 4.5.2.3.
filler: Person, or service, who produces the observations (fills the
order) requested by the requestor. The word is synonymous with "producer" and
includes diagnostic services and clinical services and care providers who
report observations about their patients. The clinical laboratory is a
producer of lab test results (filler of a lab order), the nursing service is
the producer of vital signs observations (the filler of orders to measure vital
signs), and so on. See ORC-4-filler number, Section 4.5.2.4.
battery: A set of one or more observations identified as by a single
name and code number, and treated as a shorthand unit for ordering or
retrieving results of the constituent observations. Vital signs, electrolytes,
routine admission tests, and obstetrical ultrasound are all examples. Vital
signs (conventionally) consist of diastolic and systolic blood pressure, pulse,
and respiratory rate. Electrolytes usually consist of Na+, K+, Cl-, and HCO3-.
Routine admission tests might contain CBC, Electrolytes, SMA12, and Urinalysis.
(Note that the elements of a battery for our purposes may also be batteries).
Obstetrical ultrasound is a battery made up of traditional component
measurements and the impression, all of which would be returned as separate
"results" when returned to the requestor. In keeping with the mathematical
conventions about set, a battery can be a single observation.
The word battery is used in this specification synonymously with the word
profile or panel. The individual observation elements within a battery may be
characteristic of a physiologic system (e.g., liver function tests), or many
different physiologic systems.
observation: A measurement of a single variable or a single value
derived logically and/or algebraically from other measured or derived values.
A test result, a diastolic blood pressure, and a single chest xray impression
are examples of observations.
segment (record): A typed aggregate of data elements (fields)
describing one complete aspect of a message. For example, the information
about one order is sent as type of segment (OBR), the information related to an
observation is sent as another segment (OBX).
The segment in a message is analogous to a record in a database, and in
previous versions of the standard we used record in place of the word segment.
We have changed the nomenclature to be consistent with HL7 and other standards
organizations in this version.
field: One specific attribute of a segment, for example, patient
diagnosis, which may contain aggregates of data elements further refining the
basic attribute.
repeated value: some fields may contain many repeat data elements. For
example, the diagnoses field may contain many different diagnoses.
field components: a field entry may also have discernable parts or
components. For example, the patient's name is recorded as last name, first
name, and middle initial, each of which is a distinct entity separated by a
component delimiter (sub-subfield in ASTM E1238-94 -- see footnote 15).
Narrative reports from services such as Radiology usually consist of a number
of subcomponents (e.g., a chest xray report may consist of a description, an
impression, and a recommendation). Other studies, such as echocardiograms,
contain analogous components, as well as numeric observations (e.g., left
ventricular and diastolic diameter). Surgical pathology reports may contain
information about multiple specimens and reports: the anatomic source, the
gross description, the microscopic description, and a diagnostic impression for
each specimen.
The current standard treats each component of a narrative report as a separate
"test" or observation. Just as a CHEM12 is transmitted as an order segment
(OBR) plus 12 OBX segments, a chest xray would be transmitted as an order (OBR)
segment plus three OBX segments, one for the description, one for the
impression, and one for the recommendations. Similarly, an EKG report would be
transmitted as an order segment (OBR), two OBX segments for the impression and
recommendation, and additional OBX segments for each EKG measurement, e.g. the
PR interval, QR interval, QRS axis, and so on.
We have defined code suffixes for constructing observation IDs for the common
components of narrative reports (see Table 7.1). The observation identifier
for each such component is obtained by concatenating the observation battery ID
(the ID in OBR-4-universal service ID of the preceding OBR from any
coding system) with the appropriate suffix. The observation ID for a chest
xray impression, for example, would be the chest xray observation ID (if CPT4,
it would be 71020), a subcomponent delimiter, and the suffix, "IMP", i.e.,
71020&IMP.
This same combining rule applies to other coding systems including local and
universal procedural codes (see Chapter 4). For example, if a local code for
EKG was E793, and the locally agreed upon designation for that local code was
EKG, the impression would be identified as E793&IMP^^99EKG.
Note: The "99EKG" in the 3rd component is included to indicate a local code. The EKG's description, in this case, would be E793&GDT^^99EKG. |
Optionally, when agreed upon by the sender and receiver, the "observation ID"
component of a result segment could be omitted when they are the same as the
observation ID of the preceding OBR. In this case, only the ampersand and the
suffix would have to be sent, e.g., &IMP or &REC, in
OBX-3-observation identifier of a result segment. The full code would
be assumed as the test identifier (recorded in the order segment) plus the
category identifier recorded in the observation segment.
Figure 7-1 Observation ID suffices
Coded Results |
Suffix |
Type |
Diagnostic
impression |
IMP |
CE |
The following subsections define each of the suffixes.
When the suffix is IMP (OBX-3-observation identifier), the result is a
diagnosis or finding, stored as a CE data type. When multiple distinct
diagnostic impressions are being reported, for example, mitral valve prolapse
and aortic stenosis, each distinct impression should be sent in a separate OBX
segment. More than one code may be included within one coded result segment,
but only when such codes are modifiers of the principal impression, e.g. to
report additional detail about the finding, not to report an entirely different
finding.
The coded data type for impressions does not mean that a reporting service
must actually code all such impressions. The diagnostic impression can be sent
as dictated text, but the text should be sent in the second component of the CE
data type to distinguish it from code, i.e. it should be preceded by a
component delimiter, e.g. ^congestive heart failure.
When multiple text impressions are being reported, they should be reported in
separate OBX segments to indicate that they are distinct impressions.
When the suffix is REC (OBX-3-observation identifier), the value is a
CE result, representing the reading physician's recommendations about repeat
testing, follow up or therapy. For example, when an ambiguous lesion result is
seen on a mammogram, the reading physician might recommend a repeat mammogram
in six months, or a needle biopsy immediately. The recommended procedures are
recorded as codes and/or text descriptions in the coded identifier structure.
If more than one follow up study is recommended, each such recommendation is
sent in a separate REC.
The confirming procedure OBX suffix identifies additional studies used to
confirm the diagnosis reported in the IMP OBX. If, for example, electron
microscopy was done to confirm a surgical pathology diagnosis, the identifier
for electron microscopy OBX-3-observation identifier would be stored as
the value field of an observation ID with a confirming procedure suffix.
Confirming procedures are most important in surgical pathology reports. But
they might also be used by services such as endoscopy, to record the fact that
a biopsy, culture, etc., was taken during the procedure.
A coded result segment with a suffix of MED (OBX-3-observation
identifier) indicates that the segment contained information about
medication given as part of the procedure -- contrast medication, medication
intended to invoke a physiologic response (e.g., to be used in stress testing)
or premedication. When patients receive more than one procedure medication,
each medication should be reported in a separate OBX medication segment. If
the transmitting system has codes available for medications, they would be
recorded as the first component of OBX-3-observation identifier. The
name and/or the dosages could be included in the second component of
OBX-5-observation value.
Some diagnostic studies include observations about more than one anatomic site
within one report. If, for example, a patient had an appendectomy incidental
to gallbladder surgery, the pathologist's assessment of both specimens would
usually be included under a single specimen number in one report. Each
distinct anatomic site would be reported as a separate OBX segment with a
suffix of ANT (OBX-3-observation identifier).
When required, the instrument or device which generated an observation can be
transmitted as an additional "result" of the study. In this case, the suffix
of OBX-3-observation identifier is DEV. Examples include: an automated
instrument in the laboratory; an imaging device and model number in radiology;
or an automatic blood pressure machine on the ward. The device is specified as
a coded entry in anticipation that these identifiers could be specified as
codes. Initially, we expect that most of the information about devices will be
transmitted as text in the second component of the CE identifier.
The general description suffix identifies the description component of a
diagnostic studies. In the case of anatomic pathology, it applies to the
macroscopic (gross) description of the specimen. If the description consists
of multiple paragraphs, the paragraphs should be separated by repeat delimiters
so that the receiving computer can display them as paragraphs. It will not be
necessary to include a description segment for a report when the impression
segment says it all, e.g., for normal studies or studies such as EKG, whose
reports are traditionally terse.
For most studies, a secondary description will not be needed. In the case of
surgical pathology, however, the microscopic description is a separate part of
the report. It describes the histology as seen through the microscope. The
microscopic description will be sent in a segment with the suffix MDT in
OBX-3-observation identifier.
This is free text stored in a result segment whose OBX-3-observation
identifier has a suffix of TCM for technician comment. It is used to
record information about technical performance of the procedure, usually
recorded by the technician.
Use to report information that is added as an addendum after the original
dictation and sent as a separate labeled section of the report.
Use to record the date-time that a problem was first perceived to exist.
Use to record the date-time that a problem became inactive, i.e., the problem
was cured or remitted.
When the reader of a diagnostic report compares the results for the current
study with those of a previous study, this suffix allows them to report the
nature of the comparison study as a separate result, i.e., an OBX segment with
a segment whose observation ID has a suffix of CMS. Ordinarily, this would not
be required because the observation ID in the other comparison OBX's would
identify the test, if any of the other comparison values were transmitted.
When the reader of a diagnostic procedure compares the current results with a
previous study, this suffix allows them to report the date-time of the previous
study (time optional) as a separate result within the current report.
When the reader of a diagnostic procedure compares the current results with
those of a previous study on the same patient, this suffix allows them to
report the results (impression) of the previous study as a discrete result
within the current report.
When a diagnostic service reports a comparison between the current and a
previous study, this suffix is used to report the degree of change (e.g., much
worse, worse, minimal worsening, no change, slightly better, better, much
better, returned to normal) as a separate result within the report.
In current dictation, information about comparison is usually contained in the
descriptions of the study. The provision of the comparison suffixes listed
above do not imply a requirement to send this information as separate
components. The comparison variables are only meant to be enabling. When a
system would like to transmit them as discrete report components, these
suffixes give them the option.
When an observation has a predicted value as is the case for many spirometry
tests, this suffix identifies the predicted observation as distinguished from
the actual observation. The AS4 code for forced vital capacity is 94010.1 (see
appendix 7A). The predicted forced vital capacity would be 94010.1&PRD.
This is a computed observation = (actual observation)/(predicted observation).
For forced vital capacity the percent predicted would be identified as
94010.1&PPR.
An observation might be taken before and after a drug is given. This occurs
especially in Spirometry. The predose observation is identified by the base
ID. The post drug measure is identified by the AFD suffix. Using the AS4 base
code for the forced vital capacity the post drug result would be identified by
94010.1&AFD.
The post drug predicted value is identified by the suffix, ADP. Following the
pattern of the above example, it would be 94010.1&ADP.
The percent predicted after drug is identified by applying the suffix, APP to
the base code -- 94010.1&APP if using the AS4 code for forced vital capacity.
To accommodate the additional observations included in the expanded scope of
this revision, we have expanded the AS4 codes in Appendix 7.A for identifying
clinical observations. [1]
When an observation's value is measured on a continuous scale, one must report
the measurement units within the units field of the OBX segment. In HL7
version 2.2 of the specification, all fields that report units are of data type
CE. The default coding system for the units codes consists of the ISO
abbreviation for a single case unit (ISO 2955-83) plus extensions that do not
collide with ISO abbreviations. We designate this coding system as ISO+ (see
Figure 7-5). Both the ISO unit's abbreviations and the extensions are defined
in section 7.1.4.2. The ISO+ abbreviations are the codes for the
default coding system. Consequently, when ISO+ units are being used, only ISO+
abbreviations need be sent, and the contents of the units field will be
backward compatible to HL7 version 2.1 and ASTM 1238-88.
We strongly encourage observation producers to use ISO+ abbreviated units
exclusively, but permit the use of other code systems, including US customary
units (ANSI X3.50) and locally defined codes where necessary. Local units are
designated "L" or 99zz where z is an alpha numeric character. ANSI X3.50 -1986
provides an excellent description of these standards, as well as a table of
single case abbreviations for US customary units such as foot or gallon.
We had originally intended to include the ANSI X3.50 - 1986 US customary units
in the default ISO+ coding system. However, there are overlaps between ISO's
abbreviations and the abbreviations for US customary units. For example, "ft"
is the abbreviation for foot in US customary units and for femtotesla in ISO;
"pt" is the abbreviation for pint in US customary and for picotesla in ISO.
(Be aware that the ANSI document also differs from the ISO document regarding
the abbreviation of a few ISO units, as well.) In order to avoid potential
ambiguity, we have defined another coding system, designated ANS+. It includes
the US customary units (e.g., feet, pounds) and "ISO" abbreviations defined in
ANSI X3.50-1986, as well as other non-metric units listed in Table 24 and the
ISO combinations of these units. Be aware that a few of the ANSI "ISO" unit
abbreviations differ from their abbreviations in ISO (see note at bottom of
table 24). Because the ANS+ specification includes both "ISO" and US customary
units, as well as miscellaneous non-metric units, some of the abbreviations are
ambiguous. Although there should be little confusion, in the context of a
particular observation, this ambiguity is a good reason for avoiding ANS+ unit
codes when possible.
When ANS+ units codes (abbreviations) are being transmitted, "ANS+" must be
included in the 3rd (6th) component of the field. If the units of distance
were transmitted as meters (ISO+) it would be transmitted as "m" because ISO+
is the default coding system for units. However, if transmitted in the US
customary units of feet, the units would be transmitted as "ft^^ANS+". When
required, the full text of the units can be sent as the second component in
keeping with the CE data type conventions.
Both ISO and ANSI also provide a set of mixed case abbreviations, but these
abbreviations cannot be translated to single case without loss of meaning, and
should not be used in this specification whose content is required to be case
insensitive.
ISO builds its units from seven base dimensions measured as meters, kilograms,
seconds, amperes, kelvins, moles and candelas (see Figure 7-2). Other units
can be derived from these by adding a prefix to change the scale and/or by
creating an algebraic combination of two or more base or derived units.
However, some derived units have acquired their own abbreviations (see Figure
7-2). Abbreviations for U.S. customary units are given in Figure 7-3.
The ISO rules, well explained in ANSI X3.50, provide a way to create units of
different scales by adding "multiplier" prefixes. These prefixes can be
expressed as "words" or abbreviations. In this standard we are only concerned
with the abbreviations.
Figure 7-2 ISO single case units abbreviations
Units |
Abbreviation |
Units |
Abbreviation |
Units |
Abbreviation |
Base units code/abbreviations |
|||||
ampere |
a |
kelvin |
k |
meter |
m |
candela |
cd |
kilogram |
kg |
mole |
mol |
second |
s | ||||
Derived units with specified name and abbreviation |
|||||
coulomb |
c |
hour |
hr |
pascal |
pal |
day |
d |
joule |
j |
volt |
v |
degree Celsius |
cel |
minute (time) |
min |
watt |
w |
farad |
f |
newton |
n |
weber |
wb |
hertz |
hz |
ohm |
ohm |
year |
ann |
Other units |
|||||
atomic mass unit |
u |
grey |
gy |
minute of arc |
mnt |
bel |
b |
henry |
h |
radian |
rad |
decibel |
db |
liter |
l |
siemens |
sie |
degree |
deg |
lumen |
lm |
steradian |
sr |
gram |
g |
lux |
lx |
tesla |
t |
See ISA 2955-1983 for full set |
The ISO abbreviations for multiplier prefixes are given in Figure 7-4.
Prefixes ranging from 10-18 (1/billion billionth) to 1018
(a billion billion) are available. The single case abbreviation for kilo
(x1000) is "k". A unit consisting of 1000 seconds would be abbreviated as
"ks", 1000 grams as "kg", 1000 meters as "km", and so on. Some prefixes share
the abbreviation of a base unit. Farad and femto, for example,
(10-18) both have the abbreviation of "f". To avoid confusion, ISO
forbids the use of solitary prefixes. Thus, "f" always means farad, "ff" would
mean 1 million billionth of a farad. Compound prefixes are not allowed.
A unit can be raised to an exponential power. Positive exponents are
represented by a number immediately following a unit's abbreviation, i.e., a
square meter would be denoted by m2. Negative exponents are signified by a
negative number following the base unit, e.g., "1/m2" would be
represented by as "m-2". The multiplication of units is signified by a period
(.) between the units, e.g., meters X seconds would be denoted "m.s". Notice
that spaces are not permitted. Division is signified by a slash (/) between
two units, e.g. meters per second would be denoted as "m/s". Algebraic
combinations of ISO unit abbreviations constructed by dividing, multiplying, or
exponentiating base ISO units, are also valid ISO abbreviations units.
Figure 7-3 ANSI+ unit codes for some U.S. customary units
Units |
Abbreviation |
Units |
Abbreviation |
Units |
Abbreviation |
LENGTH |
VOLUME |
TIME |
|||
inch |
in |
cubic foot |
cft |
year |
yr |
foot |
ft |
cubic inch |
cin |
month |
mo |
mile (statute) |
mi |
cubic yard |
cyd |
week |
wk |
mautical mile |
nmi |
tablespoon |
tbs |
day |
d |
rod |
rod |
teaspoon |
tsp |
hour |
hr |
yard |
yd |
pint |
pt |
minute |
min |
quart |
qt |
second |
sec | ||
gallon |
gal |
||||
ounce (fluid) |
foz |
||||
AREA |
MASS |
||||
square foot |
sqf |
dram |
dr |
||
square inch |
sin |
grain |
gr (avoir) |
||
square yard |
syd |
ounce (weight) |
oz |
||
pound |
lb |
||||
Other ANSI units, derived units, and miscellanous |
|||||
**British thermal unit |
btu |
**degrees fahrenheit |
degf |
**millirad |
mrad |
cubic feet/minute |
cft/min |
**feet/minute |
ft/min |
**RAD |
rad |
Note the abbreviations for conventional U.S. units of time are the same as ISO, except for year. ISO = ANN, AMSI = yr. The metric units in X3.50 are the same as ISO, except for: pascal ("pa" in ANSI, "pal" in ISO); ANSI uses "min" for both time and arc while ISO uses "mnt" for minutes of arc; and in ISA seconds are abbreviated "s", in ANSI, "sec". |
|||||
|
|||||
**Non-metric units not explicitly listed in ANSI |
Figure 7-4 Single case ISO abbreviations for multiplier prefixes
|
|
|
| ||
|
|
|
|
|
|
peta |
1015 |
pe |
femto |
10-15 |
f |
tera |
1012 |
t |
pico |
10-12 |
p |
giga |
109 |
g |
nano |
10-9 |
n |
mega |
106 |
ma |
micro |
10-6 |
u |
kilo |
103 |
k |
milli |
10-3 |
m |
hecto |
102 |
h |
centi |
10-2 |
c |
deca |
101 |
da |
deci |
10-1 |
d |
Figure 7-5 lists the abbreviations for common ISO derived units. It also
includes standard unit abbreviations for common units, e.g., Milliequivalents,
and international units, mm(Hg), and for counting per which we denote by a
division sign, a denominator, but no numerator, e.g., /c, that are not part of
the above referenced ISO standards.
Figure 7-5 Common ISO derived units and *ISO extensions
Name |
Code/Abbr. |
Name |
Code/Abbr. |
1/L |
/l
|
Picosecond |
ps |
* Starred items are not genuine ISO, but do not conflict. |
Local codes can be used for the units by indicating the code source of "L" in
the third component. In the case of local codes, the text name of the codes or
the description of the units should also be transmitted (in the second
component), so that the receiving system can compare the results with results
for the same measurement sent by another service. An "L" should be stored in
the third component to indicate that the code is locally defined. More
specialized local code designations, as specified in the CE data type
definition, can also be employed.
The triggering events that follow are all served by the ORU (Observational
report - Unsolicited) or the ORF (Observational Report Response) messages in
combination with ACK and QRY. Each triggering event is listed below, along
with the messages exchanged, and the segments that comprise the messages. The
notation used to describe the sequence, optionality, and repeating of segments
is described in Chapter 2, "Format for Defining Abstract Messages."
With the type (OBX) defined in this chapter, and the OBR defined in Chapter 4,
one can construct almost any clinical report as a three-level hierarchy, with
the PID segment defined in Chapter 3 at the upper level, an order record (OBR)
at the next level and one or more observation records (OBX) at the "bottom."
One result segment (OBX) is transmitted for each component of a diagnostic
report, such as an EKG or obstetrical ultrasound or electrolyte battery.
ORU Observational Results (Unsolicited) Chapter
MSH Message Header 2
{
[
PID Patient Identification 3
[{NTE}] Notes and comments 2
[PV1] Patient Visit 3
]
{
[ORC] Order common 4
OBR Observations Report ID 7
{[NTE]} Notes and comments 2
{
[OBX] Observation/Result 7
{[NTE]} Notes and comments 2
}
}
}
[DSC] Continuation Pointer
ACK Acknowledgement Chapter
MSH Message header 2
MSA Message acknowledgement 2
Note: The ORC is permitted but not required in this message. Any information that could be included in either the ORC or the OBR must be included in the OBR on reporting. Notice also that the ORU (and the QRY) messages accommodate reports about many patients. |
Many report headers (OBR) may be sent beneath each patient segment, with many
separate observation segments (OBX) beneath each OBR. Note segments (NTE) may
be inserted after any of the above segments. The note segment applies to the
entity that immediately precedes it, i.e., the patient if it follows the PID
segment, the observation if it follows the OBR segment, and the individual
result if it follows the OBX segment.
QRY Query
Chapter
MSH Message Header 2
QRD Query Definition 2
QRF Query Filter 2
ORF Observational Report Chapter
MSH Message Header 2
MSA Message Acknowledgement 2
{
QRD Query Definition 2
[ QRF ] Query Filter 2
[ PID ] Patient ID 3
[{NTE}]
}
{
[ ORC ] Order common
OBR Observation request 7
{[NTE]} Notes and comments 2
{
[OBX] Observation/Result 7
{[NTE]} Notes and comments 2
}
}
[DSC] Continuation Pointer 2
Display-oriented results reporting is described in Chapter 2, Section 2.7.
The QRD and QRF segments are defined in Chapter 2, Section 2.8.
The subject filters contained in the QRD and QRF segments are defined by local
agreement between the inquiring system and the ancillary system.
The Set ID fields in the various segments (including PID) are used to count
the number of segments of one kind transmitted at one level of the hierarchy.
The Query Result Level field of the QRD determines the amount of data
requested. See Chapter 2, Section 2.10.
The full definitions of many segments required for reporting clinical
observations are included in other chapters. The patient identifying segment
(PID) is provided in Chapter 3. The NTE segment is in Chapter 2. We include a
section on OBR in this chapter, but it includes only a brief description and a
table listing the fields. This is included for the convenience of the reader.
The full definition of the OBR segment is given in Chapter 4, Section 4.8.
In the reporting of clinical data, the OBR serves as the report header. It
identifies the observation set represented by the following atomic
observations. It includes the relevant ordering information when that applies.
It contains many of the attributes that usually apply to all of the included
observations.
When a set of observations is ordered, the order message contains an OBR
segment. However, observations can be collected and reported without an
antecedent order. When observations are reported, the report message also
includes one or more OBR segments. So, the OBR segment is like a turn-around
document. Some fields in the OBR segment apply only to the ordering message
and some to the reporting message. To those familiar with health care
procedures, these should be obvious from their names (e.g., transcriptionist or
principal result interpreter could only apply to the reporting phase).
However, we have also flagged them in Table 7.6 to indicate whether placer,
filler, or both may send data in a given field.
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
Item# |
Element Name |
1 |
4 |
SI |
|
|
|
00237 |
Set
ID - Observation Request |
The complete description of these fields is given in Chapter 4.
* Placer sends
[dagger] Filler sends
[daggerdbl] Either may send - depends on whether specimen is required and
who collects, filler or placer.
The OBX segment is used to transmit a single observation or observation
fragment. It represents the smallest indivisible unit of a report. Its
structure is summarized in Figure 7-7.
Its principal mission is to carry information about observations in report
messages. But the OBX can also be part of an observation order (see Section
4.2). In this case, the OBX carries clinical information needed by the filler
to interpret the observation the filler makes. For example, an OBX is needed
to report the inspired oxygen on an order for a blood oxygen to a blood gas
lab, or to report the menstrual phase information which should be included on
an order for a pap smear to a cytology lab. Appendix 7.A includes codes for
identifying many of pieces of information needed by observation producing
services to properly interpret a test result.
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
ITEM# |
ELEMENT NAME |
1 |
4 |
60 |
SI |
O |
|
|
00569 |
Set
ID - Observational Simple |
7.3.2.0 OBX field definitions
Definition: sequence number. For compatibility with ASTM.
Definition: format of the observation value in OBX. If the value is CE then
the result must be a coded entry. When the value type is TX or FT then the
results are bulk text. The valid values for the value type of an observation
are listed in Table 0125 - value type.
The observation value must be represented according to the format for the data
type defined in Chapter 2, Control Section. For example, a PN consists of 6
components, separated by component delimiters.
Although NM is a valid type, observations which are usually reported as
numbers will often have the string (ST) data type because non-numeric
characters are often reported as part of the result, e.g., >300 to indicate
the result was off-scale for the instrument. In the example, ">300", ">"
is a symbol and the digits are considered a numeric value.
All HL7 data types are valid except CM, because it is not a specific data
type, CQ, because units for OBX-5-observation value are always
specified explicitly in an OBX segment with OBX-6-units and SI sequence
ID, because it only applies to HL7 message segments.
The RP value (reference pointer) must be used if the actual observation value
is not sent in OBX but exists somewhere else. For example, if the observation
consists of an image (document or medical), the image itself cannot be sent in
OBX. The sending system may in that case opt to send a reference pointer. The
receiving system can use this reference pointer whenever it needs access to the
actual image through other interface standards, e.g., ACR-NEMA, or through
appropriate data base servers.
Value |
Description |
ST |
String
data. |
Components: <identifier> ^ <text> ^ <name of coding
system>^ <alternate identifier> ^ <alternate text> ^ <name of
alternate coding system>
Definition: unique identifier for the observation. The format is that of the
Coded Element (CE). Example: 93000.3^P-R interval.
In most systems the identifier will "point" to a master observation table that
will provide other attributes of the observation that may be used by the
receiving system to process the observations it receives. A proposed set of
message segments for transmitting such master observation tables is part of the
master file proposal now under ballot. The relation of an observation ID to a
master observation table is analogous to the relationship between a charge code
(in a billing record) and the charge master.
When local codes are used as the first identifier in this field we strongly
encourage sending a universal identifier as well to permit receivers to
equivalence results from different providers of the same service (e.g., a
hospital lab and commercial lab that provides serum potassium to a nursing
home). One possible "universal" identifier is a combination of CPT4 codes and
the AS4 extensions developed by ASTM (see Appendix 7A) which cover all of the
common test results and physiologic variables (e.g., BP, Pulse).
Definition: used to distinguish between multiple OBX segments with the same
observation ID organized under one OBR. For example, a chest xray report might
include three separate diagnostic impressions. The standard requires three OBX
segments, one for each impression. By putting a 1 in the Sub-ID of the first
of these OBX segments, 2 in the second, and 3 in the third, we can uniquely
identify each OBX segment for editing or replacement.
The sub-identifier is also used to group related components in reports such as
surgical pathology. It is traditional for surgical pathology reports to
include all the tissues taken from one surgical procedure in one report.
Consider, for example, a single surgical pathology report that describes the
examination of gallbladder and appendix tissue. This report would be
transmitted roughly as shown in Figure 7-8.
Figure 7-8 Example of sub-identifier usage
OBR|1|||88304&SURG
PATH REPORT... |
The example in Figure 5 has two segments for each component of the report, one
for each of the two tissues. Thus, there are two 88304&ANT segments; there
are two 88304&GDT segments, and there are two 88304&MDT segments.
Segments that apply to the gallbladder all have the sub-identifier 1. Segments
that apply to the appendix all have sub-identifier 2.
The observation sub ID has other grouping uses. It can be used to organize
the reporting of some kinds of fluid intakes and outputs. For example, when
intake occurs through multiple intravenous lines; a number of separate
observations (OBX segments), the intake volume, the type of intake (Blood, D5W,
Plasma, etc), the site of the IV line, etc. may be needed for each intravenous
line, each requiring a separate OBX segment. If more than one IV line is
running, we can logically link all of the OBX segments that pertain to the
first IV line by assigning them an observation sub ID of 1. We can do the same
with the second IV line by assigning them a sub ID 2 and so on. The same would
apply to the outputs of surgical drains when there are multiple such drains.
Use a null or 1 when there is no need for multiples.
Definition: value observed by the observation producer. OBX-2-value
type contains the data type for this field according to which observation
value is formatted. It is a required field in the OBX segment.
Representation
This field contains the value of OBX-3-observation identifier of the
same segment. Depending upon the observation, the data type may be a number
(e.g., a respiratory rate), a coded answer (e.g., a pathology impression
recorded as SNOMED), or a date-time (the date-time that a unit of blood is sent
to the ward). An observation value is always represented as the data type
specified in OBX-2-value type of the same segment. Whether numeric or
short text, the answer shall be recorded in ASCII text.
Reporting Logically Independent Observations
The main sections of dictated reports, such as radiologic studies or history
and physicals, are reported as separate OBX segments. In addition, each
logically independent observation should be reported in a separate OBX segment,
i.e. one OBX segment should not contain the "result" of more than one logically
independent observation. This requirement is included to assure that the
contents of OBX-6-units, OBX-8-abnormal flags, and
OBX-9-probability can be interpreted unambiguously. The electrolytes
and vital signs batteries, for example, would be reported as four separate OBX
segments. Two diagnostic impressions, e.g., congestive heart failure and
pneumonia, would also be reported as two separate OBX segments whether reported
as part of a discharge summary or chest xray report. Similarly, two bacterial
organisms isolated in a single bacterial culture would be reported as two
separate OBX segments.
Though two independent diagnostic "statements" cannot be reported in one OBX
segment, multiple categorical responses are allowed (usually as CE data types
separated by repeat delimiters), so long as they are fragments (modifiers) that
together construct one diagnostic statement. Right upper lobe (recorded as one
code) and pneumonia (recorded as another code), for example, could be both
reported in one OBX segment. Such multiple "values" would be separated by
repeat delimiters.
Multiple OBX Segments With The Same Observation ID and Sub ID
In some systems, a single observation may include "fragments" of more than one
data type. The most common example is a numeric result followed by coded
comments (CE). In this case, the logical observation can be sent in more than
one OBX segment. For example, one segment of numeric or string data type for
the numeric result and another segment of CE data type for coded comments. If
the producer was reporting multiple coded comments they would all be sent in
one OBX segment separated by repeat delimiters because they all modified a
single logical observation. Multiple OBX segments with the same observation ID
and sub ID should always be sent in sequence with the most significant OBX
segment (the one that has the normal flag/units and or reference range and
status flag) first. The value of OBX-6 through 12 should be null in any
following OBX segments with the same OBX-3-observation identifier and
OBX-4-observation sub-ID. For the purpose of replacement or deletion,
multiple OBX segments with the same observation ID and sub ID are treated as a
unit. If any are replaced or deleted, they all are replaced.
Coded Values
When an OBX segment contains values of CE data types, the observations are
stored as a combination of codes and/or text. In Section 7.4.4, examples of
results that are represented as CE data types are shown in the first and second
OBX segments of OBR 1 and the first and second OBX segments of OBR 2. The
observation may be an observation battery ID (for recommended studies), a
diagnostic code or finding (for a diagnostic impression), or an anatomic site
for a pathology report, or any of the other kinds of coded results.
It is not necessary to always encode the information stored within a coded
observation. For example, a chest xray impression could be transmitted as pure
text even though it has a CE data type. In this case, the test must be
recorded as the second component of the "result code", e.g.,
OBX|1|CE|71020&IMP|1|^CONGESTIVE HEART FAILURE.
However, separate impressions, recommendations, etc., even if recorded as pure
text, should be recorded in separate result segments. That is, congestive
heart failure and pneumonia should not be sent as:
OBX|1|CE|71020&IMP|1|^CONGESTIVE HEART FAILURE AND PNEUMONIA|
but as:
OBX|1|CE|71020&IMP|1|^CONGESTIVE HEART FAILURE|
OBX|2|CE|71020&IMP|2|^PNEUMONIA|.
Even better would be fully-coded results that include computer understandable
codes (component 1) instead of, or in addition to, the text description
(component 2).
Components: <identifier> ^ <text> ^ <name of coding
system>^
<alternate identifier> ^ <alternate text> ^ <name of alternate
coding system>
Definition: units have a data type of CE. The default coding system for the
units codes consists of the ISO+ abbreviation for a single case unit (ISO
2955-83) plus extensions, that do not collide with ISO abbreviations (see
introductory section to this chapter). We designate this coding system as
ISO+. Both the ISO unit's abbreviations and the extensions are defined in
section 7.1.4 and listed in Figure 7-5. The ISO+ abbreviations are the
codes for the default coding system. Consequently, when ISO+ units are being
used, only ISO+ abbreviations need be sent, and the contents of the units field
will be backward compatible to HL7 vs. 2.1.
Components: numeric values: <lower limit - upper limit>, e.g., for
potassium, 3.5 - 4.5.
alphabetical values: the normal value may be reported in this
location
Definition: if the observation quantifies the amount of a toxic substance,
then the upper limit of the range identifies the toxic limit. If the
observation quantifies a drug, the lower limits identify the lower therapeutic
bounds and the upper limits represent the upper therapeutic bounds above which
toxic side effects are common.
Definition: a table lookup indicating the normalcy status of the result. We
strongly recommend sending this value when applicable. If the observation is
an antibiotic susceptibility, the interpretation codes are: S=sensitive;
R=resistant; I=intermediate; MS=moderately sensitive; VS=very sensitive. (See
ASTM 1238 - review for more details). Refer to Table 0078 - abnormal
flags for valid entries.
When the laboratory can discern the normal status of a textual report, such as
chest xray reports or microbiologic culture, these should be reported as N when
normal and A when abnormal. Multiple codes, e.g., abnormal and worse, would be
separated by a repeat delimiter, e.g., A~W.
Value |
Description |
L |
Below
low normal |
For microbiology sensitivities only: |
|
S |
Sensitive |
Definition: probability of a result being true for results with categorical
values. It mainly applies to discrete coded results. It is a decimal number
represented as an ASCII string that must be between 0 and 1, inclusive.
Definition: refer to table 0080 - nature of abnormal testing for valid
codes.
Value |
Description |
A |
An
age-based population |
Definition: refer to table 0085 - Observation result status for valid
codes. This field reflects the current completion status of the results for one
Observation Identifier.
Value |
Description |
C |
Record
coming over is a correction and thus replaces a result |
Definition: changes in the observation methods that would make values
obtained from the old method not comparable with those obtained from the new
method.
Null if there are no normals or units. If present, a change in this date
compared to date-time recorded, the receiving system's test dictionary should
trigger a manual review of the results to determine whether the new observation
ID should be assigned a new ID in the local system to distinguish the new
results from the old.
Definition: permits the producer to record results-dependent codes for
classifying the observation at the receiving system. This field should be
needed only rarely, because most classifications are fixed attributes of the
observation ID and can be defined in the associated observation master file
(see description in section 7.1).
However, there are a few cases when such controls vary with the value of the
observation in a complex way that the receiving system would not want to
re-calculate. An example is an antimicrobial sensitivity result. Some systems
prefer to display only the sensitivity results of inexpensive antibiotics
depending upon the organism, the source of the specimen and the patients
allergy status. The sending service wants to send all of the sensitivities so
that certain privileged users (e.g., Infectious Disease specialists) can review
all of the results but nonprivileged users would see only the "preferred"
antibiotics to which the organism was sensitive. We expect that other cases
also occur.
Definition: required in two circumstances. The first is when the
observations reported beneath one report header (OBR) have different dates.
This could occur in the case of queries, timed test sequences, or clearance
studies where one measurement within a battery may have a different time than
another measurement.
It is also needed in the case of OBX segments that are being sent by the
placer to the filler, in which case the date of the observation being
transmitted is likely to have no relation to the date of the requested
observation. In France, requesting services routinely send a set of the last
observations along with the request for a new set of observations. The date of
these observations is important to the filler laboratories.
In all cases, the observation date-time is the physiologically relevant
date-time or the closest approximation to that date-time. In the case of tests
performed on specimens, the relevant date-time is the specimen's collection
date-time. In the case of observations taken directly on the patient (e.g.,
xray images, history and physical), the observation date-time is the date-time
that the observation was performed.
Components: <identifier> ^ <text> ^ <name of coding
system>^ <alternate identifier> ^ <alternate text> ^ <name of
alternate coding system>
Definition: unique identifier of the responsible producing service. It
should be reported explicitly when the test results are produced at outside
laboratories, for example. When this field is null, the receiving system
assumes that the observations were produced by the sending organization. This
information is needed to satisfy CLIA regulations in the US. The code for
producer ID is recorded as a CE data type. In the US, the Medicare number of
the producing service is suggested as the identifier.
Components: <physician ID> ^ <family name> ^ <given
name> ^ <middle initial or name> ^ <suffix (e.g., JR or III)> ^
<prefix (e.g., DR)> ^ <degree (e.g., MD)> ^ <source table
ID>
Definition: when required, the identifier of the individual directly
responsible for the observation (i.e., the person who either performed or
verified it). In a nursing service, the observer is usually the professional
who performed the observation (e.g., took the blood pressure). In a
laboratory, the observer is the technician who performed or verified the
analysis. The code for the observer is recorded as a CE data type. If the
code is sent as a local code, it should be unique and unambiguous when combined
with OBX-15-producer ID.
The following is a query of the EKG system for the data for a particular
patient number 0123456-1 for reports that have been modified or created since
1/1/88. The response ends with a continuation pointer. A continuation query
follows, in reply to which a continutation response is sent.
Query (QRY)
MSH|^~\&|CBD||EKG||||QRY^R02|CDB22222|P<CR>
QRD|198904180943|R|I|Q4412|||10|RD|0123456-1|RES<CR>
QRF|EKG||198801010000<CR>
Response
MSH|^~\&|EKG||CDB||||ORF^R04|X981672|P<CR>
MSA|AA|CDB22222|P<CR>
QRD|198904180943|R|I|Q4412|||10|RD|0123456-1|RES<CR>
QRF|EKG||198804010000<CR>
PID|1|0123456-1||ROBERTSON^JOHN^H|||||||9821111<CR>
OBR|1|43215^OE|98765^EKG|93000^EKG
REPORT|R|198801111000|198801111330|||RMT||||
... 1988011 11330|?|P030||||||198801120930||||||88-126666|A111|
... VIRANYI ^ANDREW<CR>
OBX|1|ST|93000.1^VENTRICULAR RATE(EKG)||91|/MIN|60-100<CR>
OBX|2|ST|93000.2^ATRIAL RATE(EKG)||/MIN|60-100<CR>
OBX|3|ST|93000.3^PR INTERVAL||0|/MSEC|1.06-.10<CR>
OBX|4|ST|93000.4^QRS INTERVAL||368|/MSEC|.18-.22<CR>
...
...
...
OBX|8|CE|93000&IMP^EKG DIAGNOSES|1|^ATRIAL FIBRILATION<CR>
OBX|9|CE|93000&IMP^EKG DIAGNOSIS|2|^ST DEPRESSION<CR>
OBX|109|FT||93000&ADT^EKG COMMENT||\.in+4\\.ti-4\ 1. When compared with
EKG of
... 31-oct-88 ventricular rate has increased by 30 bpm.\.sp\\.ti-4\
... 2. Criteria for Lateral infarct are no longer present.<cr>
OBR|2|43217^OE|98767^EKG|93000^EKG
REPORT||198810311004|198810311004||||?|||198810311004|?|P030||||||198810311744||||||
... 88-126689|A122|BREAL|WILLIAM<CR>
...
...
...
DSC|1896X22;0123456-1<CR>
Continuation Query
MSH|^~\&|CDB||EKG||||QRY^R02|CDB22289|P<CR>
QRD|198904180943|R|I|Q4412|||10|RD|0123456-1|RES<CR>
QRF|EKG||1988040100000<CR>
DSC|1896X22;0123456-1<CR>
Continuation Response
MSH|^~\&|EKG||CDB||||ORF^R04|X981672|P<CR>
MSA|AA|CDB22289|P<CR>
QRD|198904180943|R|I|Q4412|||10|RD|0123456-1RES<CR>
QRF|EKG||198804010000<CR>
PID||0123456-1||ROBERTSON^JOHN^H|||||||9821111<CR>
OBR| ...
...
...
The following is an unsolicited transmission of radiology data.
MSH|^~\&|XRAY||CDB||||ORU^R01|K172|P<CR>
PID|1|0123456-1||ROBERTSON^JOHN^H|||||||9821111<CR>
OBR|1|X89-1501^OE|78912^RD|71020^CHEST XRAY AP &
LATERAL|R|198703291530|19873290800|||JBM|N <CR>
OBX|1|CE|71020&IMP^RADIOLOGIST'S IMPRESSION|4||^MASS LEFT LOWER
LOBE|1||A<CR>
OBX|2|CE|71020&IMP|2|^INFILTRATE RIGHT LOWER LOBE|||A<CR>
OBX|3|CE|71020&IMP|3|^HEART SIZE NORMAL|||N<CR>
OBX|4|FT|71020&GDT|1|circular density (2 x 2 cm) is seen in the
posterior segment of
... the LLL. A second, less well-defined infiltrated circulation density
is
... seen in the R mid lung field and appears to cross the minor
fissure#<CR>
OBX|5|CE|71020&REC||71020^Follow up CXR 1 month||30-45|<CR>
Example message (from ASTM 1238-91)
Laboratory message: electrolytes, CBC, sed rate, blood cultures and
sensitivities ... <CR>
MSH...
PID|...
Eletrolytes:
OBR|1|870930010^OE|CM3562^LAB|80004^ELECTROLYTES|R|198703281530|198703290800|||
...
401-0^INTERN^JOE^^^^MD^L|N|||||SER|^SMITH^RICHARD^W.^^^DR.|(319)377-4400|
... This is requestor field #1. Requestor field #2|Diag.serv.field
#1.|
... Diag.serv.field #2.|198703311400|||F<CR>
OBX|1|ST|84295^NA||150|mmol/l|136-148|H||A|F|19850301<CR>
OBX|2|ST|84132^K+||4.5|mmol/l|3.5-5|N||N|F|19850301<CR>
OBX|3|ST|82435^CL||102|mmol/l|94-105|N||N|F|19850301<CR>
OBX|4|ST|82374^CO2||27|mmol/l|24-31|N||N|F|19850301<CR>
CBC:
OBR|2|870930011^OE|HEM3268^LAB|85022^CBC|R|198703281530|198703290800|||401-0 ^
... INTERN^JOE^^^^MD^L|N||||BLD|^SMITH^RICHARD^W.^^^DR.|(319)377-4400|This
is
... requestor field #1.|This is Requestor field #2.|This is lab field
#1.|Lab
... field #2.|198703311400|||F<CR>
OBX|1|ST|85018^HGB||13.4|GM/DL|14-18|N||S|F|19860522<CR>
OBX|2|ST|85014^HCT||40.3|%|42-52|L||S|F|19860522<CR>
OBX|3|ST|85041^RBC||4.56|10*6/ml|4.7-6.1|L||S|F|19860522<CR>
OBX|4|ST|85021.11^MCV||88|fl|80-94|N||S|F|19860522<CR>
OBX|5|ST|85021.21^MCH||29.5|pg|27-31|N||N|F|19860522<CR>
OBX|6|ST|85041.25^MCHC||33|%|33-37|N||N|F|19860522<CR>
OBX|7|ST|85048^WBC||10.7|10*3/ml|4.8-10.8|N||N|F|19860522<CR>
OBX|8|ST|85048.18^BAND NEUT.%||2|%||||F<CR>
OBX|9|ST|85048.16^SEG.NEUT.%||67|%||||F<CR>
OBX|10|ST|85048.42^LYMPH.%||29|%||||F<CR>
OBX|11|ST|84048.52^MONOCYTE.%||1|%||||F<CR>
OBX|12|ST|85012.1^EOSIN.%||2|%||||F<CR>
Sed rate:
OBR|3|870930011^OE|HEM3269^LAB|85650^ESR|R|198703281530|198703290800|||
...
401-0^INTERN^JOE^^^^MD^L|N||||BLD|^SMITH^RICHARD^W.^^^DR.|(319)377-4400|
... This is requestor field #1.|This is Requestor field #2.|This is lab
field
... #1.|Lab field #2.|198703311400|||F<CR>
OBX|1|ST|85650^ESR||7|MM/HR|0-10|N||S|F|19860522|E|1|1792|27<CR>
Parent micro result, identifies organism
OBR|4|2740X^OE|BC376^MIC|87040^Blood
culture|R|198703280600|198703290800|||
... 99-2^JONES&COLLECTOR|N|Hepatitis risk||198703290830|Bld|
... 4010^INTERN^JOE^^^^MD^L|X3472|Requestor field 1|Requestor field
2|
... Producer's field 1|Producer's field
2|198703301000|35.00|MB|F|<CR>
OBX|1|CE|87040^Blood culture|1|^E Coli|||A||F<CR>
OBX|2|CE|87040^Blood culture|2|^S Aureus|||A||F<CR>
Child micro result, gives antibiotic sensitivities for organism identified in
first OBX of parent
OBR|5|2740X^OE|BC402^MIC|87186^Antibiotic
MIC|R|198703281230|198703290800||||G|
... Hepatitis
risk||198703290830|Bld|401.0^INTERN^JOE^^^^MD^L|X3472|||||
...
198703310900|40.00|MB|F|87040^1|||2740X&OE^BC376&MIC<CR>
OBX|1|ST|87186.2^Ampicillin MIC||<2|ug/ml||S|<CR>
OBX|2|ST|87186.5^Carbenicillin MIC||<16|ug/ml||S|<CR>
OBX|3|ST|87186.21^Gentamicin MIC||<2|ug/ml||S|<CR>
OBX|4|ST|87186.33^Tetracycline MIC1||<1|ug/ml||S|<CR>
OBX|5|ST|87186.29^Piperacillin MIC||<8|ug/ml||S|<CR>
OBX|6|ST|87186.15^Cefuroxime MIC||<2|ug/ml||S|<CR>
OBX|7|ST|87186.16^Cephalothin MIC||<8|ug/ml||S|<CR>
OBX|8|ST|87186.3^Amoxicillin-Clavulanate||<4|ug/ml||S|<CR>
OBX|9|ST|87186.56^Thienamycin MIC||<1|ug/ml||S|<CR>
OBX|10|ST|87186.17^Chloramphen MIC||<4|ug/ml||S|<CR>
OBX|11|ST|87186.37^Tobramycin MIC||<2|ug/ml||S|<CR>
OBX|12|ST|87186.7^Amakacin MIC||<4|ug/ml||S|<CR>
OBX|13|ST|87186.36^Trimeth-Sulf MIC||<2/38|ug/ml||S|<CR>
OBX|14|ST|87186.8^Cefazolin MIC||<2|ug/ml||S|<CR>
OBX|15|ST|87186.39^Cefoxitin MIC||<2|ug/ml||S|<CR>
OBX|16|ST|87186.14^Ceftriazone MIC||<4|ug/ml||S|<CR>
OBX|17|ST|87186.44^Ceftazidime MIC||<2|ug/ml||S|<CR>
OBX|18|ST|87186.34^Timentin MIC||<8|ug/ml||S|<CR>
OBX|19|ST|87186.41^Ciprofloxacn-MIC||<1|ug/ml||S|<CR>
Second micro child result, gives sensitivities or organism identified by
Second OBX of parent
OBR|6|2740X^OE|BC403^MIC|87186^Antibiotic
MIC|R|198703281230|198703290800||||G|
... Hepatitis
risk||198703290830|Bld|401.0^INTERN^JOE^^^^MD^L|X3472|||||
...
198703310900|40.00|MB|F|87040^2|||2740X&OE^BC376&MIC<CR>
OBX|1|ST|87186.2^Ampicillin MIC||<8|ug/ml||R|<CR>
OBX|2|ST|87186.18^Clindamycin MIC||<.25|ug/ml||S|<CR>
OBX|3|ST|87186.21^Gentamicin MIC||<1|ug/ml||S|<CR>
OBX|4|ST|87186.19^Erythromycin MIC||<.5|ug/ml||S|<CR>
OBX|5|ST|87186.27^Oxacillin MIC||<.5|ug/ml||S|<CR>
OBX|6|ST|87186.38^Vancomycin MIC||<2|ug/ml||S|<CR>
OBX|7|ST|87186.28^Penicillin MIC||<8|ug/ml||R|<CR>
OBX|8|ST|87186.16^Cephalothin MIC2||<2|ug/ml||S|<CR>
OBX|9|ST|87186.17^Chloramphen MIC||<4|ug/ml||S|<CR>
OBX|10|ST|87186.1^Amikacin MIC||<16|ug/ml||S|<CR>
OBX|11|ST|87186.41^Ciprofloxacn-MIC||<1|ug/ml||S|<CR>
OBX|12|ST|87186.31^Rifampin MIC||<1|ug/ml||S|<CR>
This example of the body of reports shows the following observation from what
are usually free text reports. The text within these examples that begins with
**-- and ends with --** are explanatory comments, not a formal part of the
message. The following outline shows the segments that are included in this
example message.
a) patient identifying record (PID)
b) EKG order record (OBR)
c) EKG coded result record (OBX)
d) EKG result records (OBX):
1) ventricular rate
2) atrial rate
3) QRS width
4) PR interval
e) order record for chest x-ray (OBR)
f) two diagnostic impressions for CXR (OBX)
g) description record for CXR (OBX)
h) a recommendation record for CXR (OBX)
i) an order record for surgical pathology (OBR)
j) a gross description record for pathology showing use of anatomy fields
(OBX)
k) a microscopic description record for pathology (OBX)
l) vital signs request (OBR)
m) six vital signs (OBX)
n) part of the physical history (OBR & OBX)
o) end record
... MSH ...
... PID ...
**--Order record for EKG--**
OBR|1|P8753^OE|EK5230^EKG|93000^EKG|R|198703281530|198703290800|||401-0^INTERN^JOE^^^^MD^L|N
<CR>
**--Two interpretation records for EKG--**
**--[In this case, the result observation ID assumes the observation code in
the order record.]--**
OBX|1|CE|&IMP|1|^Sinus bradycardia|||A <CR>
OBX|2|CE|&IMP|2|^Occasional PVCs|||A <CR>
**--Four numeric results for EKG--**
**--[The AS4 code is an extension of the CPT4 code (93000) for EKG plus
extension .1, .2, etc., as detailed in Appendix 7.A.]--**
OBX|3|ST|93000.2^Ventricular rate||80|/min|60-100 <CR>
OBX|4|ST|93000.3^Atrial rate||80|/min|60-100 <CR>
OBX|5|ST|93000.5^QRS width||.08|msec|.06-.10 <CR>
OBX|6|ST|93000.4^PR interval||.22|msec|.18-.22 <CR>
**--Order record for CXR--**
OBR|2|P8754^OE|XR1501^XR|71020^Chest Xray AP &
Lateral|R|198703281530|198703290800|||
401-0^INTERN^JOE^^^^MD^L|N <CR>
**--Two CXR diagnostic impressions--**
OBX|1|CE|71020&IMP^Radiologist's
Impression|1|.61^RUL^ACR~.212^Bronchopneumonia^ACR|||A<CR>
OBX|2|CE|71020&IMP|2|51.71^Congestive heart
failure^ACR|||A<CR>
**--CXR Description with continuation records--**
OBX|3|TX|71020&GDT||Infiltrate probably representing bronchopneumonia
in the right lower lobe. Also pulmonary venous congestion cardiomegaly and
cephalization, indicating early congestive heart failure.<CR>
**--Recommendations about CXR report to follow up one month with a repeat
CXR--**
OBX|4|CE|71020&REC||71020^Followup CXR 1 month^AS4<CR>
**--Order record for pathology report--**
OBR|3|P8755^OE|SP89-739^SP|88304^Surgical Path
Report|R|198703281530|198703290800|||401-0^INTERN^JOE^^^^MD^L|N<CR>
OBX|1|CE|&ANT|1|Y0480-912001^orbital region^SNM<CR>
**--Gross description record (with overflow) for pathology--**
OBX|2|TX|&GDT^GrossSpecimenDescription|1|The specimen is received in
four containers. The first is labeled with the patient's name and consists of
three fragments of reddish-brown tissue each of which measures 2 mm in greatest
dimension. They are wrapped in tissue paper and submitted in toto in a single
cassette| <CR>
**--Microscopic description record for pathology--**
OBX|3|TX|&MDT^MicroscopicDescription|1|A|Sections of the first specimen
received for frozen section diagnosis reveal thick walled, ramifying vessels
lined by a single layer of flattened endothelial cells. The thick smooth
muscle walls exhibit no malignant cytologic features nor do the endothelial
lining cells. Within the same specimen are also found fragments of fibrous
connective tissue, bone, and nerve which are histologically
unremarkable<CR>
**--Vital signs--**
OBR|4|P8756^OE|N2345^NR|3000.02^VITAL
SIGNS|R|198703281530|198703290800|||401-0^INTERN^JOE^^^^MD^L|N<CR>
OBX|1|ST|1002.3^BP DIAS||90|mm(hg)|60-90|<CR>
OBX|2|ST|1002.2^BP SYS||120|mm(hg)|100-160|<CR>
OBX|3|ST|1002.4^BP MEAN||100|mm(hg)|80-120|N<CR>
OBX|4|ST|1006.2^HEART RATE||74|/min|60-100|N<CR>
OBX|5|ST|1002.1^BP METHOD||MANUAL BY CUFF|<CR>
OBX|6|ST|1006.1^PULSE METHOD||MANUAL BY PALP|<CR>
**--Part of the patient's history--**
OBR|5|P8568^OE|HX2230^CLN||2000^HISTORY|R|198703281530|198703290800|401-0^INTERN^JOE^^^^MD^L|N<CR>
OBX|1|CE|2000.40^CHIEF COMPLAINT|| ... <CR>
OBX|2|ST|2000.01^SOURCE||PATIENT<CR>
OBX|3|TX|2000.02^PRESENT ILLNESS||SUDDEN ONSET OF CHEST PAIN. 2 DAYS, PTA
ASSOCIATED WITH NAUSEA, VOMITING & SOB. NO RELIEF WITH ANTACIDS OR NTG. NO
OTHER SX. NOT PREVIOUSLY ILL.<CR>
.
.
and so on.
Organisms and other observations/tests are reported using multiple OBX
segments. The granularity expected for HL7 culture reports is one observation
per organism.
All OBX segments which have the same observation ID and sub-ID are part of a
single observation.
Each organism in a culture battery is assigned a unique OBX-4-observation
sub-ID (and is therefore a separate observation). The organism name is
given in OBX-5-observation value (results). It is recommended, but not
required that the organism name may change over time, but the corresponding
observation sub-ID never changes. (The observation ID will be identical for
all organisms reported.)
Recommended:
OBX||CE|organism^413^L|1|^E. Coli|
OBX||CE|organism^413^L|2|^S. Aureus|
Not Recommended:
OBX||CE|organism1^413^L|1|^E. Coli|
OBX||CE|organism2^413^L|1|^S. Aureus|
Each antibiotic should be reported as a separate (OBX) observation where the
Observation ID is a code for the antibiotic. (OBXs for non-antibiotic
observations and related information may be present in the same battery.)
MIC and Kirby Bauer sensitivity results cannot be combined in the same OBX
segment. An OBX can contain an MIC value (in OBX-5-observation value
(results)) and OBX-8-abnormal flag that indicates whether the organism
is sensitive, resistant, or intermediate (see Table 0078 under abnormal flag
fields).
Or, an OBX can contain a Kirby Bauer result string (e.g., "sensitive") in the
Observation Results field and the Kirby Bauer interpretation in
OBX-8-abnormal flags (e.g., "S").
A sensitivity battery may only contain results corresponding to a single
organism that has been previously reported in a culture battery.
The following is the preferred, but not required method of organizing data
about antibiotic sensitivities.
A sensitivity battery may only contain results corresponding to a single
organism that has been previously reported in a culture battery.
A sensitivity battery is always a child "order" to a culture battery.
OBR-29-parent number (parent's filler order number) in the sensitivity
OBR is equal to OBR-3-filler order number in the parent culture OBR and
is used to link the two batteries logically.
The sensitivity battery also contains a linkage back to a particular organism
in the culture battery. OBR-26-parent result of the sensitivity OBR
contains two components--OBX-3-observation identifier (code only) and
OBX-4-observation sub-ID of the OBX in the culture battery which
contains the organism name.
The identity of an organism/isolate is expected to be refined over time. When
an organism identification changes, the parent culture battery can be resent
without resending the child sensitivity battery.
The case may occur where a sensitivity battery is reported on an organism
which has not yet been identified. In this case, it is required that a
placeholder OBX for the organism name be reported in the corresponding culture
battery so that OBR-26-parent result in the sensitivity OBR will point
to a valid organism OBX in the culture battery. Transmission of an organism
OBX (in the culture battery) with the Sub-ID field valued must precede the
sensitivity battery which uses the identical Sub-ID in OBR-26-parent
result.
Discussion and examples:
Order Micro Results (Blood Culture)
MSH|^~\&|LAB1||DESTINATION||19910127105114||ORU^R03|LAB1003929
PID|||900329493||PETRSN~DAVID|||927
PV1||I|
ORC|NW|
OBR||A485388^OE|H29847^LAB1|BLOOD CULTURE|||
Result for Culture
ORC|RE
OBR||A485388^OE|H29847^LAB1|BLOOD CULTURE||
OBX||FT|SDES^SOURCE||BLOOD-RAPID||
OBX||FT|EXAM^MICROSCOPIC||GRAM POSITIVE COCCI IN GROUPS||
OBX||FT|ORGANISM^IDENTIFIER|1|ISOLATE 1||
Result for Sensitivity
ORC|RE
OBR||A485388^OE|H29848^LAB1|BT1^SUSCEPTIBILITY BATTERY|||||MC|to
field
... 26|ORGANISM^1|||A485388&OE^H29847&LAB1|
OBX||CE|ACAPEN^PENICILLIN||0.5|R||
OBX||CE|ACHNAF^NAICILLIN||1|R||
OBX||CE|ACHCCLI^CLINDAMYCIN||<=0.1|S||
Result for Culture ID
ORC|RE
OBR||A485388^OE|H29847^LAB1|BLOOD CULTURE||
OBX||FT|ORGANISM^IDENTIFIER|1|STAPH EPI||
New Result for Culture ID
ORC|RE
OBR||A485388^OE|H29847^LAB1|BLOOD CULTURE||
OBX||FT|ORGANISM^IDENTIFIER|1|STAPH EPI SERO TYPE 3||
Assumptions
1. All OBXs in the parent order must employ the same coding scheme.
2. The Sub-ID of the parent OBXs (result) cannot change.
Suppose an order has been placed to the EKG system for three EKGs to be
performed on successive days. These results can be reported in various
ways.
1. The EKG application needs to communicate to anyone the results of the 1st
EKG:
ORU message:
MSH|...
PID|...
OBR|||89-551^EKG|93000^EKG REPORT|... // 1ST child OBR.
OBX||ST|93000.1^VENTRICULAR RATE (EKG)|...
OBX||ST|93000.2^...
...
...
OBX||FT|93000.14^EKG COMMENT|...
OBR|... // other observation
segments to follow
- Notice that this report is without reference to the original order.
- No ORC is required because the identifying Filler's Order Number (and other
ORC fields) are carried in the OBR segment.
2. The EKG application needs to communicate to anyone the original order
information, the details of the child orders, the fact of the child spin off,
and the results of all three EKGs:
ORU message:
MSH|...
PID|.
ORC|PA|A226677^OE|89-450^EKG|... // original order's ORC.
OBR||||93000^EKG REPORT|... // original order segment
ORC|CH|A226677^OE|89-451^EKG<CR> // 1st child ORC.
OBR||||93000^EKG REPORT|... // 1st EKG child OBR.
OBX||ST... // 1st EKG report
OBX||ST...
...
OBX||FT...
ORC|CH|A226677^OE|89-452^EKG<CR> // 2nd child ORC.
OBR||||93000^EKG REPORT|... // 2nd EKG child OBR.
OBX||ST... // 2nd EKG report
OBX||ST...
...
OBX||FT...
ORC|CH|A226677^OE|89-453^EKG<CR> // 3rd child ORC.
OBR||||93000^EKG REPORT|... // 3rd EKG child OBR.
OBX||ST... // 3rd EKG report
OBX||ST...
...
OBX||FT...
... // Other parts of message might
follow.
- In this case, we are transmitting the information about the fact of child
spin off, the original order and the results all at the same time. Thus, this
form of the ORU message reports not only the results of an order, but all of
its associated ordering information including the original OBR for three EKGs
that was replaced by three separate OBR EKG segments.
Reporting body weight and height with a creatinine clearance.
MSH|...
PID|...
ORC|NW|... // New order.
OBR||P42^PC||98142.1^Creatinine Clearance|...
OBX||ST1010.1^Body Weight|62|kg<CR>
OBX||ST1010.3^Height|190|cm<CR>
ORC|NW|... // Next order.
...
1. We have not devised universal code extensions for all diagnostic studies.
Appendix 7.AS4 provides codes for common clinical and nursing variables and
codes for extending battery procedure codes to identify important
components.
This standard is highly dependent on the availability of a set of codes for
uniquely identifying the observations carried in an OBX segment. Here we
suggest a set of codes for the most common clinical observations such as
diastolic blood pressure, urine output per shift, pulse, and Glascow coma
score. We include these codes both to make concrete how the standard can be
used to transmit most kinds of clinical information, as well as to encourage
standardization of clinical variable codes. Note that some clinical variables
have categorical (multiple choice) rather than numerical answers. We have
included a minimal list of suggested answer sets for these variables.
We have also included a set of codes from The Health Outcomes Institute[4], representing the most common outcome variables
such as the Rand Short Form-36, and the Interstudy TyPE Specifications.)
Most procedure systems do not provide individual codes for the component
observations of tests such as the urinalysis, blood cell differential count and
antibiotic sensitivities as the separate observation recorded as part of an EKG
tracing, cardiac echoes, etc., because the constituents of these batteries
cannot be ordered separately. This appendix also provides extensions for
uniquely identifying the constituents of such test "batteries", such as
differential whole blood, all cultured urinology, EKG, cardiac echo, etc.
CPT4 is the base procedure coding system used to illustrate how to extend such
procedural coding systems in this appendix. Because CPT4 is universally
available in the US to code procedures, it is a candidate coding system.
However, CPT4 has many weaknesses. It does not precisely identify many tests,
it does not provide sufficient discrimination about the method used, and, in
the case of imaging procedures, it often aggregates many separate activities
under one code. ICCS is another candidate. It is a more elegant and
comprehensive procedure classification than CPT4. It has a hierarchical
structure, is more complete (regarding the individual tests included). But at
the present, it is proprietary and is not complete regarding less common tests,
nor does it discriminate by method. SNOMED III will include a procedure coding
system. SNOMED III's codes for diseases, topology, and pathology, are very
good. The procedure codes may be equally good. ASTM E31.12 has an on going
effort to define vocabulary (and abbreviations) for chemistry tests. Euclides[5] has an active effort to define codes for all
clinical laboratory tests. Within the scope of both the Euclides and E31.12
effort, the AS4 extensions for test batteries would not be needed.
We have chosen the new codes for the clinical variables to avoid any overlap
with CPT4. However, such overlap cannot be guaranteed with all procedural
coding systems. Consequently, when the clinical variables for physical exam,
etc., listed in this appendix are used with code systems other than CPT4, it is
up to the user to either include a local code system designator as the third
component CE data types with these clinical codes, or to verify that there is
no overlap with the procedural coding system of choice.
Patient specific drug/toxicology information has many dimensions and contexts.
From the perspective of a laboratory, drug levels can be measured. However,
different variables need to be defined according to the specimen type, (blood,
serum, blood cells, urine, hair), and the kind of method (quantitative,
semi-quantitative or qualitative), drug dose and timing (peak or trough). Most
of these distinctions apply to toxic substances as well.
Contextual variables are also important to drug testing. Examples are the dose
of the drug given (where the time and the units would be carried in an OBX
segment), who gave the drug, and how many hours pre-blood draw the last dose
was given. The lab usually requires that these contextual "observations" be
transmitted with the order and are usually reported back as part of the battery
that represents the drug measurement.
Drug (treatment) dosing can also be considered from the context of the
prescription for the treatment, and a number of separate drug order related
variables could be defined for each drug, so that users could transmit this
information as an OBX to a patient's computer-based flowsheet (in a critical
care unit, for example) or as part of a study of drug levels. For example, the
amount of drug given at a particular dosing time (as reported above), the
average daily dose prescribed, the total amount given to the patient, the
percent of compliance (as estimated by the patient), and so on.
In the following, we provide construction rules for building codes for such
drug variables from drug codes. Our examples are based on the World Health
Organization's drug record number (up to 6 digits) and code for salt (2
digits), for a total of 8 digits, and we identify these extended coding system
as WA. The World Health drug codes have many advantages, including
international coverage, linkage to a hierarchical code (ATC), to preferred
name, brand names and manufacturers, to multiple component drugs, and to the
American Chemical Societies(ACS) chemical codes. Moreover, it is modestly
priced. But other drug code systems (e.g., the ACS chemical codes for the
drugs, SNOMED III's drug codes, etc.) could also be used to construct these
drug related variables.
Observation Name Identifier
Urinalysis:
Root Code:
Urinalysis 81000
Extensions:
Dip stick pH .1
Specific gravity .2
Dip stick protein .3
Dip stick glucose .9
Reducing substance .4
Dip stick Hgb .5
Dip stick bilirubin .6
Dip stick ketones .7
Urine Appearance .8
Dipstick WBC esterase .10
Dipstick Nitrate .11
Dipstick Ascorbic acid .12
Dipstick Urobilinogen .13
Root Code:
Urine Miscroscopic: 81015
Extensions:
Urine WBC's .1
Urine RBC's .2
Urine WBC casts .3
Urine RBC casts .4
Urine hyaline casts .5
Urine granular casts .6
Urine waxy casts .27
Urine fatty casts .7
Urine bacteria .8
Trichomonas .9
Uric acid crystals .11
Pyrophosphate crystals .12
Cystine crystals .13
Bilirubin crystals .14
Triple phosphate crystals .15
Ca carbonate crystals .16
Ca PO4 crystals .17
Urine fat globules .18
Urine epithelial cells .19
Urine yeast-like fungi .21
Urine filamentous fungi .22
Urine unidentified crystals .23
Complete Blood Count Components:
Root Code:
Red blood cell (RBC) only 85041
White Blood Cell (WBC) 85048
Extensions:
Total neutrophil count .11
Total neutrophil, % .12
Hypersegmented neutrophil count .13
Hypersegmented neutrophil, % .14
Segmented neutrophil count .15
Segmented neutrophil, % .16
Band neutrophil count .17
Band neutrophil, % .18
Metamyelocyte count .19
Metamyelocyte, % .21
Lymphocyte count .41
Lymphocyte, % .42
Atypical lymphocyte count .44
Atypical lymphocyte, % .45
Monocyte count .51
Monocyte, % .52
Eosinophil, count .63
Eosinophil, % .64
Basophil count .59
Basophil, % .60
Promyelocyte count .53
Promyelocyte, % .54
Myelocyte count .55
Myelocyte, % .56
Blast count .57
Blast, % .58
Nucleated RBC count .59
Nucleated RBC, % .60
Other leukocyte count .61
Other leukocyte, % .62
Root Code:
Hemogram, Automated (RBC, WBC, Hgb,
Hct and indices only): 85021
Extensions:
Mean corpuscular volume--MCV .11
Mean corpuscular diameter--MCD .15
Red cell size distribution--RDW .18
Mean corpuscular hemoglobin--MCH .21
Hemoglobin distribution width--HDW .26
Mean corpuscular hemoglobin .27
Hypochromia .32
Basophilic stippling .33
Toxic Granules .34
Microcytes .35
Macrocytes .36
Atypical lymphocytes .37
Ovalocytes .38
Spherocytes .39
Schistocytes .41
Hypersegmented Neutrophils .42
Sickle cells .43
Poikilocytosis .44
Anisocytosis .45
Anisochromic .46
Platelet count Auto .47
Root Code: 85580
Platelet Count (Rees-Ecker):
Extensions:
Mean platelet volume .11
Mean platelet diameter .15
Antibiotics (Sensitivities/Levels)
Approach - Use the appropriate CPT-4 code to identify the nature of the
testing. Append the appropriate antibiotic identifier from the list below for
a complete specification.
Root Code
I.E. Agar diffusion 87181
Disk antibiotic sensitivity 87184
Minimum inhibitory concentration 87186
Minimum bacteriocidal concentration 87187
Macrotube dilution method 87188
Serum bacteriocidal titre 87197
Antibiotic level RIA 80040
Antibiotic bio assay 80042
Extensions: Add the antibiotic number to one of the above codes
to obtain a complete code, e.g., 87184.1 is the code for amikacin disk
antibiotic sensitivity, 87186.1 is the code for amikacin MIC, 80040.1 is the
code for amikacin level done by RIA.
Amdinocillin .54
Amikacin .1
Aminosalicylic acid (e.g., PAS) .58
Amoxicillin .59
Amoxicillin/clavulanic acid .3
Ampicillin .2
Ampicillin/sulbactam .53
Anasmycin .60
Azithromycin .61
Azlocillin .4
Aztreonam .43
Bacampicillin .62
Capreomycin .63
Carbenicillin .5
Cefadroxil .65
Cefamandole .6
Cefamezin .7
(do not use = cefazolin)
Cefazolin .8
Cefixime .66
Ceflacor .64
Cefmetazol .67
Cefonicid .9
Cefoperazone .11
Cefotaxime .12
Cefoxitin .39
Cefotetan .55
Cefprozil .68
Cefsulodin .56
Ceftazidime .44
Ceftizoxime .13
Ceftriaxone .14
Cefuroxime .15
Cefuroxime axetil .69
Cephalothin .16
Cephradine .70
Chloramphenicol .17
Cinoxacin .71
Ciprofloxacin .41
Clarithromycin .72
Clindamycin .18
Clofazimine .73
Cloxacillin .74
Colistimethate .75
Cyclacillin .45
Cycloserine .76
Dapsone .77
Demeclocycline .78
Dicloxacillin .79
Doxycycline .80
Enoxacin .46
Erythromycin .19
Erythromycin-sulfisoxazole .81
Ethambutol .82
Ethionamide .83
Flucytosine .84
Gentamicin .21
Imipenem/cilastatin .34
Isoniazid .85
Kanamycin .86
Lincomycin .87
Lomefloxacin .88
Methenamine hippurate .89
Methenamine Mandelate .90
Methicillin .22
Metronidazole .92
Mezlocillin .23
Miconazole .93
Minocycline .94
Minocycline .24
Moxalactam .25
Moxalactam .95
Nafcillin .96
Nalidixic acid .97
Natamycin .98
Neomycin .99
Netilmicin .42
Nitrofurantoin .26
Norfloxacin .48
Ofloxacin .49
Oxacillin .27
Oxytetracycline .100
Pefloxacin .50
Penicillin .28
Pentamidine isethionate .101
Piperacillin .29
Polymyxin B .102
Proampacin .103
Protionamide .104
Pyrazinamide .105
Pyrimethamine .106
Pyrimethamine sulfadoxine .107
Ributin .108
Rifampin .31
Rifampin-isoniazid .109
Spectinomycin .110
Streptomycin .111
Sulfa .32
Sulfisoxazole .112
Teicoplanin .51
Temafloxacin .113
Tetracycline .33
Tetracycline HCl .114
Thiabendazole .115
Ticarcillin .52
Ticarcillin/clavulanic acid .35
Tobramycin .37
Trimeth-Sulf .36
Trimethoprim .116
Trisuflapyrimidines .117
Troleandomycin .118
Vancomycin .38
ISO enzymes:
Root Code:
Creatinine phosphokinase isoenzymes 82550
Extensions:
CK MB Fraction .1
CK MM Fraction .2
CK BB Fraction .3
CK MM Isoforms .4
Root Code:
LDH isoenzymes, electrophoretic
separation 83625
LDH isoenzymes, chemical separation 83626
Extensions:
LDH Isoenzyme I .1
LDH Isoenzyme II .2
LDH Isoenzyme III .3
LDH Isoenzyme IV .4
LDH Isoenzyme V .5
Root Code:
Alkaline Phosphatase Isoenzyme 84080
Extensions:
Liver ALK PHOS ISO .1
Bone ALK PHOS ISO .2
Intestinal ALK PHOS ISO .3
Placental ALK PHOS ISO .4
Reagin ALK PHOS ISO .5
Other ALK PHOS ISO .6
Clotting Tests:
Root Code:
Prothrombin Time 85618
Extensions:
Patient Prothrombin .1
Control Prothrombin .2
Skin Tests: 86455
Codes (CPT4):
Coccidiomycosis (mm) 86490
Histoplasmosis (mm) 86510
Mumps Interacts (mm) 86540
Trichophyton (mm) 4000
Candida (mm) 4001
Days post application read (#days) 4002
Root Code:
Tuberculosis intradermal 86580
Extensions:
1st strength .1
PPD .2
2nd strength .3
Cardiac Echo:
Root Codes
Cardiac echo M mode 93300
Cardiac echo CSE 93307
Cardiac echo doppler 93320
Extensions (add the extension number of the appropriate root
code given above)
LV diameter systolic (cm) .1
LV diameter diastolic (cm) .2
LV diastolic area (cm2) .3
LV systolic area (cm2) .4
Fractional area change .5
RV diameter (cm) .6
RV diameter systolic (cm) .7
RV diameter diastolic (cm) .8
RV diastolic area (cm2) .9
RV systolic area (cm2) .10
Left atrial diameter (cm) .11
LA diameter systolic (cm) .12
LA diameter diastolic (cm) .13
Right atrial diameter (cm) .14
Aortic valve area (sq cm) .15
Interventricular septum thickness (cm) .16
LV posterior wall thickness (cm) .17
Mitral valve area (cm2) .18
Ejection fraction (%) .19
Aortic gradient (mmHg) .20
Pulmonic gradient (mmHg) .21
Cardiac Echo Impression &IMP
Cardiac Echo Recommendation &REC
Cardiac Echo Device &DEV
RV diameter (cm)
Spirometry
Root Code: 94010
Extensions:
Forced Vital Capacity (FVC) (l) .1
Vital Capacity (l) .2
FVC .5 sec (l) .3
FVC 1 sec (l) .4
FVC 3 sec (l) .5
FEV1/FVC .6
Peak expiratory flow (l/min) .7
Peak inspiratory flow (l/min) .8
Flow 50% (l/min) .9
Flow 75% (l/min) .10
F25-75 % (l/min) .11
Maximum ventilation value .12
Slow Vital Capacity .13
Inspiratory Capacity .14
Expiratory reserve volume .15
Bronchodilator use .16
Answers
Not used
Pre-bronchodilators
Post-bronchodilators
Bronchodilators ID .17
(text name of drug used)
Bronchodilator dose .18
Total lung capacity, helium (sgl. breath) .19
Total lung capacity, nitrogen (mult. breath) .20
Total lung capacity, plethysmography .21
Total resid. vol/total lung capacity .22
Drug given .23
Dose of drug .24
Spirometry Impression &IMP
Spirometry Recommendation &REC
Spirometry Device &DEV
EMG [Neurology]
(for full list, review E31.16 draft specifications,
available as listed on footnote 12, Section 2.4)
EEG [Neurology] 95816
(for full list, review E31.16 draft
specifications, available as listed
on footnote 12, Section 2.4)
OBGYN Ultrasound (OBGYN)
Root Code:
Echography, pregnant uterus,
B-scan and/or real time with
image documentation; complete 76805
Extensions/:
Fetal Biparietal diameter (cm) .1
Fetal Head circumference (cm) .2
Fetal Abdominal circumference (cm) .3
Fetal Femur length (cm) .4
Longitudinal Ovary Axis Right (cm) .5
Longitudinal Ovary Axis Left (cm) .6
Transverse Ovary Axis Right (cm) .7
Transverse Ovary Axis Left(cm) .8
A - P Ovary Axis Right (cm) .9
A - P Ovary Axis Left(cm) .10
Longitudinal Uterus Axis (cm) .11
Transverse Uterus Axis(cm) .12
A - P Uterus Axis(cm) .13
Gestational age-size (weeks) .14
Gestational age-menstrual period (months) .15
Ob-Gyn US Impression &IMP
Ob-Gyn US Recommendation &REC
Ob-Gyn US Device &DEV
CXR
Root Code:
Radiologic examination, chest
single view, frontal 71020
Extensions:
Cardiac width .1
Cardiac/thoracic ratio .2
Largest mass size (rough diameter) (cm) .3
Largest mass size height (cm) .4
# masses .5
CXR Impression &IMP
CXR Recommendation &REC
CXR Device &DEV
Endoscopy
Root Code
Esophageal endoscopy 43200
UGI endoscopy 43234
ERCP 43260
Small bowel endoscopy 44360
Sigmoidoscopy fixed 45300
Sigmoidoscopy flexible 45330
Colonoscopy 45358
Extensions
Polyp size (mm) .1
Polyp number (#) .2
Maximum polyp size (mm) .3
Max depth instrument reached (cm) .4
Ulcer(s) (#) .5
Maximum ulcer size (cm) .6
Duration of procedure (min) .7
Endoscopy impression &IMP
Endoscopy device &DEV
Endoscopy recommendation &REC
Cardiac Catheterization Measure
Cardiac Cath Measurements
Root Code: 1030
Extension:
Central Venous Pressure [mm(hg)] .1
Wedge Pressure [mm(hg)] .2
Cardiac Index (l/min/mm2) .3
Cardiac Output (l/min) .4
Left Ventricular Ejection Fraction (%) .5
LAM .6
CCW .7
Pulmonary Artery Systolic Pressure [mm(hg)] .8
Pulmonary Artery Diastolic Pressure [mm(hg)] .9
Intracoronary Pressure [mm(hg)] .10
Aortic Root Diastolic Pressure [mm(hg)] .11
Aortic Root Mean [mm(hg)] .12
LV Systolic [mm(hg)] .13
LV Diastolic [mm(hg)] .14
LV Mean [mm(hg)] .15
RA Mean [mm(hg)] .16
RV Systolic [mm(hg)] .17
RV Diastolic [mm(hg)] .18
RV Mean [mm(hg)] .19
Cardiac Catheterization Impression &IMP
Angiogram Coronary Artery Lesions
Answer given as percent obstruction
Root Code: 1101
Extension:
RCA Proximal Obstruction (%) .2
RCA Med Obstruction (%) .3
RCA Distal Obstruction (%) .4
RFDA Obstruction (%) .5
RPLS Obstruction (%) .6
1st RPL Obstruction (%) .7
2nd RPL Obstruction (%) .8
3rd RPL Obstruction (%) .9
Acute Marginal Obstruction (%) .10
RV BRANF Obstruction (%) .11
Left Anterior Descend Obstruction (%) 1102.2
LCD Proximal Obstruction (%) .3
LCD Med Obstruction (%) .4
LCD Distal Obstruction (%) .5
1st DIG Obstruction (%) .6
2nd DIG Obstruction (%) .7
1st Septal Obstruction (%) .8
Prox CX Obstruction (%) .9
Distal CX Obstruction (%) .10
Interradiate Obstruction (%) .11
1st cm Obstruction (%) .12
2nd cm Obstruction (%) .13
LAV Obstruction (%) .14
1st LPL Obstruction (%) .15
2nd LPL Obstruction (%) .16
3rd LPL Obstruction (%) .17
LPDA Obstruction (%) .18
Electrocardiographic Measures
Note: all measures will not apply to all instruments
Root Code
Holter (use for all durations) 93266
Rhythm Strip 93040
EKG 12-Lead 93000
Signal Averaged/High Resolution ECG 5000
Extension
Ventricular rate EKG/min .2
Atrial rate EKG/min .3
P interval (ms) .25
P-R interval (ms) .4
QRS - interval (ms) .5
QT - interval (ms) .6
Q wave width (ms) .7
Q wave depth (mv) .8
# PVCs (min) .9
# PACs (min) .10
ST-elevation (mv) .11
P-wave axis (deg) .12
QRS-axis (deg) .13
T-wave axis (deg) .14
EKG axis (deg) .26
EKG.Rhythm .15
Answers
Atrial fibrillation
Atrial Flutter
Atrial premature contractions (/min)
Atrial tachycardia
Artificial Pacemaker
Bigeminy
Junctional complex
Junctional tachycardia
Normal
Paired VPC
Sinus arrhythmia
Sinus bradycardia
Sinus tachycardia
Trigeminy
Ventricular Premature contractions (/min)
Ventricular Tachycardia
Pacemaker Model .16
Pacemaker type .28
Pacemaker .29
EKG Conduction .17
ST-T waves .27
Answers
Normal
1st deg block
AV Wenckebach
AV Mobitz II
AV dissociation
Right bundle branch block
Left bundle branch block
Incomplete RBBB
Incomplete LBBB
Bilateral BBB
Accelerated Conduction
Delta Wave
Cardiac Pacemaker.EKG .18
Answers
Sinus
Atrial
Ventricular
HV Bundle
Morphology Atrial.EKG .19
Answers
Normal
Right Atrial Hypertrophy RAH
Left Atrial Hypertrophy LAH
Morphology Ventricle.EKG .20
Answers
Normal
Right Ventricular Hypertrophy RVH
Left Ventricular Hypertrophy LVH
Myocardial.Infarct.EKG(Age) .21
Answers
Acute
Old
Age indeterminate
Myocardial.Infarct.EKG(Location) .22
Answers
Septal MI(V1-3)
Lateral MI(I,L,V5-6)
Interior MI(II,3,F)
High Lateral MI(I,L)
Anterior MI(V3-4)
Extensive Anterior MI(I,L,V1-0)
Anterior Septal MI(V1-4)
Anterior Lateral MI(V3-6)
EKG miscellaneous .30
EKG lead placement .31
Other Morphology.EKG .23
Answers
high peaked T wave
large U wave
Monitor duration (min) .24
Holter/Ambulatory Extensions
Holter recording duration(HH:MM) .32
Holter number of heart beats recorded .33
Holter mean heart rate (BPM) .34
Holter Maximum heart rate (BPM) .35
Holter Minimum heart rate (BPM) .36
Holter Maximum heart rate time stamp .37
Holter Minimum heart rate time stamp .38
Holter Maximum VT rate (BPM) .39
Holter SVT rate (BPM) .40
S-T depression (mm) .41
Number of ventricular ectopics .42
Number of VT runs .43
Longest VT run (number of beats) .44
Number of supraventricular ectopics) .45
Number of SVT runs .46
Longest SVT run (number of beats) .47
Number of pauses .48
Final impressions (uncoded text) .49
Signal Averaged/High Resolution ECG
Signal number of beats averaged .50
Signal number of beats detected .51
Signal QRS duration, unfiltered (ms) .52
Signal QRS duration, filtered (ms) .53
Signal RMS voltage in terminal 40 ms .54
Signal HFLA (High Frequency
Low Amplitude) .55
Duration (ms) .56
Note: the filter setting may be used as a Sub ID
for identification. At the present time, the
following filters are most commonly used - 25hz,
40hz to 250hz, 60hz to 250hz, and 80hz to 250hz.
These filter settings refer to the filtered values in
the signal averaged ECG.
EKG Impression &IMP
EKG Device &DEV
Physiologic Observations (No specific CPT-4 codes.
Have used ASTM 4-digit codes to identify)
Miscellaneous
Root Code:
Miscellaneous clinical findings: 1000
Extensions:
Stool output (ml/60min) .13
Pupil size R (mm) .14
Pupil size L (mm) .15
Glasgow Score .16
Apache score .17
CVP pressure [mm(hg)] .18
Cardiac output (l/min) .19
#Bowel movements/8hrs .20
Calorie count/shift (kcal) .21
Apgar score 1 min .22
Apgar score 5 min .23
Medical History
Root Code: 2000
Extensions:
Chief complaint .40
Source of history .01
Present illness .02
Family Hx .03
Social Hx .04
Functional status Hx .05
Travel Hx .06
Occupational Hx .07
Childhood Disease Hx .08
Surgical Procedures Hx .09
Allergy Hx .10
Medication Hx .11
Review of Systems (header): .12
Smoking Hx total (pack/yr) .30
Smoking Hx current (pack/day) .31
Dermatologic Hx .13
Head Hx .14
Eyes (vision) Hx .15
Ears (hearing) Hx .16
Nose (smell) Hx .17
Mouth/throat/teeth Hx .18
Respiratory Hx .19
Neurologic Hx .20
Musculoskeletal Hx .21
Cardiovascular Hx .22
Urinary Hx .23
Sexual/reproductive Hx .24
Date last menstrual period (OBM) .32
Menstrual status .33
Answers
Amenorrheic
Premenarche
Follicular phase
Periovulatory
Luteal phase
Amenorrheic
Menstruating
Pregnant
Postmenopausal
Birth control method .34
Answers
Not needed
Not used
Birth control pills
Condom
Cervical cap
Spermicide
Tubal Ligation
IUD
Rhythm
Diaphragm
Vasectomy
Depo-provera hormone
Endocrine Hx .35
Hematologic Hx .36
Psychiatric Hx .37
Industrial exposure Hx .38
Physical Exam
Root Code: 3000
Extensions:
General status Px .01
Vital signs Px .02
Skin Px .03
Head Px .04
Eyes Px .05
Ears Px .06
Nose Px .07
Mouth/throat/teeth Px .08
Thorax/lungs Px .09
Breasts Px .10
Heart Px .11
Abdomen Px .12
Back Px .13
Pelvic exam (female) Px .14
Genitourinary exam (male) Px .15
Rectal Px .16
Limbs/extremities Px .17
Vessels Px .18
Neurologic Px (may be used instead of
the following more discrete categories) .19
Mental status Px .20
Deep tendon reflex Px .21
Sensation Px .22
Balance, coordination Px .23
Strength Px .24
Hospital Discharge
Root Codes: 4000
Extension:
Patient Name .1
Admission Discharge .2
Discharge Date .3
Admission DX .4
Discharge DX .5
History .6
Findings .7
Procedures .8
Hospital Course .9
Consultations .10
Discharge Disposition .11
Discharge Meds .12
Discharge Instructions .13
Staff .14
Dictated by .15
Surgical Report
Root Code: 5000
Extension:
Patient .1
Date .2
Preoperative DX .3
Postoperative DX .4
Staff Surgeon .5
Resident Surgeon .6
Operation .7
Anesthesia .8
Indications .9
Findings .10
Description of Oper .11
Specimens .12
Fluids .13
Estimated Blood Loss .14
Complications .15
Dictated by .16
Body Temperature (TEMP)
NOTE: The default and preferred units are given in parentheses. The result
segment has space for a specified unit. When the measurement units differ
from the default they must be stored in the units field of the result segment.
E.g., if the temperature was transmitted as F° instead of Celsius, the
units should be transmitted using standard ANSI unit abbreviations (see section
10.7.1).
Root Code 1000
Extension:
Temp Method .1
Answer
Glass thermometer
Digital probe
Color strip
Infrared sensor
Temp.Oral (cel) .2
Temp.Rectal (cel) .3
Temp.Axillary (cel) .4
Temp.Other (cel) .5
Temp Body Source Other .6
Answers
Oral Urinary Bladder
Auxiliary Central Line
Rectal Trachea
Forehead Urinary Catheter
Temp Device .&DEV
Blood Pressure (BP)
Measure
Code
Blood Pressure = BP
Systolic Blood Pressure = SYS BP
Diastolic Blood Pressure = DIAS BP
Mean Blood Pressure= MED BP
Root Code: 1002
Extension:
BP Method .1
Answers
Manual by Palpation
Manual by Cuff & Stethoscope
Automatic Oscillatory
Automatic Auscultation
Automatic Arterial Lines
Measures (The default --standard-- unit of measure is mmHg)
BP.SYS [mm(hg)] .2
BP.DIAS [mm(hg)] .3
BP.MEAN [mm(hg)] .4
BP Measure SITE (may apply to cuff
or arterial line) .6
Answers
Right Arm Left Arm
Right Forearm Left Forearm
Right Thigh Left Thigh
Right Brachial Left Brachial
Right Radial Left Radial
Right Ulnar Left Ulnar
Right Femoral Left Femoral
Right Popliteal Left Popliteal
Right Post Fibular Left PostFibular
Right Dorsal Pedal Left Dorsal Pedal
Right Carotid Left Carotid
Umbilical
BP CUFF POSITIONS (applies only to
cuff-based methods) .7
Answers
Right Arm Left Arm
Right Forearm Left Forearm
Right Thigh Left Thigh
Right Calf Left Calf
Heart Rate (HR = Pulse)
Pulse can be ascertained by many methods - from EKG tracings, blood pressure
tracings, palpation auscultation
Root Code: 1006
Extension:
HR Method .1
Answers
Palpation
Stethoscope
Automatic BP Oscillatory
Automatic BP Auscultation
Arterial Line
EKG monitor
Impedance
HR (/min) .2
HR SITE .3
Answers
Right Arm Left Arm
Right Forearm Left Forearm
Right Thigh Left Thigh
Right Brachial Left Brachial
Right Radial Left Radial
Right Ulnar Left Ulnar
Right Femoral Left Femoral
Right Popliteal Left Popliteal
Right Post Fibular Left Post Fibular
Right Dorsal Pedal Left Dorsal Pedal
Umbilical
PULSE.STRENGTH (1-4) .4
PULSE QUALITY .5
PULSE RHYTHM .6
Answers
Regular
Irregular
Premature Beats
PREMATURE BEATS (/min) .7
Respiratory Rate (RR)
Root Code: 1007
Extension:
RR Method .1
Answers
visual
ventilator
stethoscope
chest stretch sense
pressure sense
RR (/min) .2
RR.QUAL .4
Answers
Stridor Wheezing
Labored Cyclical
General Patient State (may apply to any of the above)
Root Code: 1008
Extension:
General Measure
(Body Position) .2
Answers
Standing Lying
Sitting
Measure Exercise .3
Answers
Rest Maximum Exercise
Post Exercise
Time Post Exercise (min) .4
Maximum Exercise (EKG/min) .5
Body Weight
Root Code: 1010
Extension:
Body Weight (kg) .1
Type of Scale .2
Answer
Standing Scale Bed Scale
Height
Root Code:
Extension:
Height (cm) .3
Intake and Output
Urine Output
Root Code: 1013
Extension:
Urine.Output.Method .1
Measure as quantity urine output
Answers
Manual
Automatic
Urine.Output.Spot (ml) .2
Urine.Output.Shift.Total (ml) .3
Urine.Output.24H Total (ml) .4
Urine.Output Device &DEV
Urine.Output.Color .6
Answers
Bloody Yellow
Brown Clear
NG Output
Root Code: 1014
Extension:
Ng Output Method .1
Ng Output.Spot (ml) .2
Ng Output.Shift Total (ml) .3
Ng Output.24H Total (ml) .4
Ng Output.Device &DEV
Ng Output.Qual .6
Answers
Bloody Green
Coffeegrounds Food
Yellow Pill particles
Chest Tube Output
Root Code: 1015
Extension:
Chest Tube Output Methods .1
Chest Tube Output Spot (ml) .2
Chest Tube Output.Shift total (ml) .3
Chest Tube Output 24H total (ml) .4
Chest Tube Output Device &DEV
Chest Tube Output.Qual .6
Stool Output
Root Code: 1016
Extension:
Stool Output Method .1
Stool Output Spot (ml) .2
Stool Output.Shift Total (ml) .3
Stool Output.24H Total (ml) .4
Stool Output Device (ml) &DEV
Stool Output.Qual (ml) .6
Answers
Watery Bloody
Loose Blood-streaked
Soft
Surgical Drain Output
Root Code: 1017
Extension:
Surgical Drain Output Method .1
Surgical Drain Output Spot (ml) .2
Surgical Drain Output.Shift Total (ml) .3
Surgical Drain Output.24H Total (ml) .4
Surgical Drain Output Where (ml) .5
Surgical Drain Output.Qual (ml) .6
IV Intake
Root Code: 1020
Extension:
IV Intake Volume (ml) .1
IV Intake Type .2
IV Intake Na (mmol) .3
IV Intake Cal (kcal) .4
IV Intake K+ (mmol) .5
IV Intake Where .6
IV Intake Device &DEV
PO Intake
Root Code: 1030
Extension:
PO Intake Spot Volume (ml) .1
PO Intake Type .2
PO Intake Shift Total (ml) .3
PO Intake 24H Total (ml) .4
GT Intake (gastric tube)
Root Code: 1031
Extension:
GT Intake Spot Volume (ml) .1
GT Intake Type .2
GT Intake Shift Total (ml) .3
GT Intake 24H Total (ml) .4
NG Tube Intake
Root Code: 1032
Extension:
NG Tube Intake Spot Volume (ml) .1
NG Tube Intake Type .2
Ng Tube Intake Shift Total (ml) .3
Ng Tube Intake 24H Total (ml) .4
Peritoneal Intake
Root Code: 1033
Extension:
Peritoneal Intake .1
Peritoneal Shift Total (ml) .2
Peritoneal 24H Total (ml) .3
Drug related clinical variables (excluding antibiotic sensitivities)
Root codes (examples are WHO drug record numbers and salt extensions). The Who
codes provide unique identifiers for each single component drug at the generic
drug-salt level and every combination drug -- a total of over 6,500 chemical
substances and 8,700 multiple ingredient drugs.
Chloroquine phosphate 000010 02
Chloroquine sulfate 000010 03
Chloroquine diorotate 000010 05
Chloroquine hydrochloride 000010 06
Atromid-S 000013 01
Amantadine hydrochloride 000559 02
Amantadine sulfate 000559 01
To construct a code for identifying the variable type for drug X, append the
string that identifies the drug variable type to the WHO record number code for
drug X. Measurements labeled QN are measures of amount. Measurements labeled QL
are qualitative, given as CE codes, indicating presence or absence.
Codes related to drug measurement:
Drug X peak serum level QN .1
Drug X trough serum level QN .2
Drug X time post dose level drawn .3
Drug X dose given (see below)
Drug X random serum level QN .4
Drug X random serum level QL .5
Drug X urine level spot QN .6
Drug X urine level spot QL .7
Drug X urine level 24 hr QN .8
Drug X saliva measure QL .9
Drug X saliva measure QN .10
Drug X hair measure QL .11
Drug X hair measure QN .12
Drug X RBC measure QN .13
Drug X frequency of dosing (ST) e.g., BID, TID
Codes related to dosing and prescription:
Drug X dose amount given .21
(the date-time of dose would be recorded in
OBX-15 and units in OBX-6 used to report the
dose given before a peak or a trough)
Drug X dose route given .22
(CE data type use, HL7 route codes)
Drug X who prescribed (CE)
Drug X dose prescribe a point in time .22
E.g., if dose was 5 mg three times per day (TID)
value would be "5", and units "mg"
Drug dose prescribed average per day (NM) .23
E.g., if dose was 5 mg TID the value would
be 15 and units mg. If dose was 5 mg
alternating with 10 mg on alternate days,
the value would be 7.5 and units would be mg
Drug dose percent compliance patient
estimate (NM) .24
This is recorded as patients estimate of
percent of doses taken. Could be more than
100%. E.g., if he/she missed half of the
afternoon dose of twice a day insulin and
none of the morning doses the percent compliance
would be 75%)
Drug dose percent compliance dispensing
estimate (NM) .26
This is compliance estimated by pharmacy
dispensing. (Could be more than 100%)
Drug dose percent compliance automatic count .27
This records the actual drug doses removed
from an automatic pill dispenser compared to
the number that was supposed to be take over
a unit time.
Number of doses per day. .28
Recorded as the number of doses taken per day.
For if prescribed three times a day its value
would be 3. If four times a day or every 6 hours,
it would be 4. If every other day it would be .5
Drug dose frequency instructions (TX) .29
Drug prescribing instructions full (TX) .30
The full instructions as written by the physician
Cumulative dose (total dose of drug
given relative to a time) .31
Date time of cumulative dose started .32
Health Outcome Variables (from Health Outcomes Institute)
The following lists a large number of health outcomes variables and their
codes. (The code system designation is HI) available from the Health Outcomes
Institute (17). The Health Outcomes Institute is collecting outcomes variables
such as those defined in the RAND 36 questions health status questionnaire, and
the InterStudy TyPE specifications. These are being used by a consortium of 36
large group practices. The full questionnaires are available from the Health
Outcomes Institute (2001 Killebrew Dr, Suite 122, Bloomington, MN 55425).
We list the variables here to give concrete examples of outcome variables that
are being used in real outcomes data bases, and to provide yet another
illustration of how OBX segments can communicate data related to different
master code files.
The codes listed are the complete codes for Health Outcomes Institute, not
extensions intended for constructing codes.
GENERAL HEALTH STATUS
In general, would you say your health is: 1.1
Change in Health in General Over One Year
Change in health over last year 2.1
Physical Function
Vigorous activities limited by health 3.1
Moderate activities now limited by health 3.2
Lifting or carrying groceries limited by health 3.3
Climbing several flights of stairs limited by health 3.4
Climbing one flight of stairs limited by health 3.5
Bending, kneeling or stooping limited by health 3.6
Walking more than a mile is limited by health 3.7
Walking several blocks is limited by health 3.8
Walking one block is limited by health 3.9
Bathing or dressing self is limited by health 3.10
Role Physical Items
Limit amount of time spent on work 4.1
Accomplish less than you would like 4.2
Limited in kind of work performed 4.3
Difficulty performing work 4.4
Role Mental Items
Cut down amount of time spent on work or other
activities - past 4 we 5.1
Accomplish less than you would like over the last
4 weeks 5.2
Didn't do work or other activities as carefully as
usual over the past 5.3
Social Function Items I
Extent physical/emotional problems interfered with
social activities 6.1
Pain Items I
Pain experienced over last four weeks 7.1
Pain Items II
Extent pain interferes with normal work, last four weeks 8.1
General Health Perceptions
I seem to get sick a little easier than other people 11.1
I am as healthy as anybody I know 11.2
I expect my health to get worse 11.3
My health is excellent 11.4
Present Height and Weight (Feet, Inches, Pounds)
Patient height 110.1
Three Item Depression Screener
Two weeks or more of past year was depressed 121.1
Two years in life feeling depressed or sad most days 121.2
Felt depressed or sad much of the time in past year 121.3
Energy, Fatigue, Emotional Status (InterStudy)
Did you feel full of pep? 122.1
Have you been a nervous person? 122.2
Have you felt so down nothing could cheer you? 122.3
Have you felt calm and peaceful? 122.4
Did you have a lot of energy? 122.5
Have you felt downhearted and blue? 122.6
Did you feel worn out? 122.7
Have you been a happy person? 122.8
Did you feel tired? 122.9
Health limits social activity 122.10
Initial Diagnosis Related to Hip Replacement
Progression of Disease - Clinical & Radiological
Clinical progression of disease 132.1
Radiologic progression of disease 132.2
Failure of Previous Operations Other Than THR
Failure of previous operations other than THR 133.1
Complications of Total Hip Replacement
THR complications 134.1
THR complication type 134.2
Previous Hip Surgeries
Previous hip surgeries 135.1
Procedures of previous hip surgeries 135.2
Lab Tests Done During Clinic Visit
Were the tests performed this visit outside of
specified ranges 137.2
Leg Lengths
hip leg length 140.1
hip study - leg length measurement method 140.2
Trendelenburg Lurch/Sign
trendelenburg lurch 141.1
hips trendelenburg sign left 141.2
hips trendelenburg sign right 141.3
Asthma Awakens at Night
awakens at night 146.1
Type of Hip Replacement and Acute Complications
acute hip complications 206.1
type of complication 206.2
type of hip replacement 206.3
Post-Joint Replacement Radiographic Evaluation
post op radiographic evaluation 207.1
Form Administration Information
hip administration, who completed form 208.1
Operative Hip
Operative hip 224.1
Racial Background
Respondents racial background 364.1
Patient of Hispanic/Spanish ancestry 364.2
Income and Number of Dependents
Family's total income 366.1
How many people are dependent on family income 366.2
Have You Been Told by your Dr.
You Have Asthma?
Have you ever been told by a doctor that you asthma? 368.1
About How Old Were You When Your
Asthma Began?
About how old were you when your asthma began? 369.1
Have You Ever Been Hospitalized for Asthma?
Have you ever been hospitalized for asthma? 370.1
Most recent asthma hospitalization 370.2
Asthma hospitalizations last 6 months 370.3
When Was the Last Severe Flare-Up
of Your Asthma?
Last severe flare-up of asthma 371.1
Number of severe flare-ups last 6 months 371.2
Severe asthma treatment site 371.3
Enough Infor. by Your Doctor About Asthma?
Enough infor. by your Dr. about asthma? 374.1
Have You Received Written Direction
About Your Med
How you received written directions about
your Medicine. 375.1
How Often Have Asthma Attacks Awakened
You?
How often have asthma attacks awakened
you from sleep? 376.1
How Often Do You Have Symptoms of Asthma?
How often have you had symptoms of asthma
when you awaken to start 377.1
Has Your Asthma Impaired Your
Performance at Work?
Has your asthma impaired you performance
at work, school, or in other 378.1
Based On Your Asthma Have You Had Problems
at Work?
Cut down on work or other activities 379.1
Accomplished less than would have liked 379.2
Limited in kind of activities 379.3
Difficulty performing activities 379.4
Does Your Asthma Cause You To Feel
Anxious, Etc.
Anxiousness, depression, irritability
due to asthma 380.1
Your Asthma Interfered With Your Normal
Activities
Your asthma interfered with your normal social
activities with family 381.1
Have You Missed From Work Because of Asthma?
Have you missed from work, school, or your
usual activities because o 382.1
Is Your Activity Limited by Other Condition?
Is your physical activity limited by any condition
other than asthma? 383.1
During the Past 4 Weeks Having Feelings
of Anxious
Cut down on time spent on work or other activities 384.1
Accomplished less than would have liked 384.2
Didn't do work or activities as carefully as possible 384.3
What Medication Do you Take to Control
Your Asthma
Taken Prednisone, Medrol, or another steroid
pill/cortisone in last 6 385.1
Taken Prednisone, Medrol, or other
steroid/cortisone for short period 385.2
Number of treatments last 6 months 385.3
How regularly is medications used to
control asthma 385.4
Number of times needed to suddenly increase
dosage to control asthma 385.5
Steroid/cortisone injection last 6 months 385.6
Hip - Post Discharge Antithrombotic Methods
Coumadin - Post discharge 386.1
Heparin - Post discharge 386.2
Other Drug - Post discharge 386.3
Other mechanical - Post discharge 386.4
None - Post discharge 386.5
Do You Take Any Other Pills or Liquids For
Asthma?
Other pills or liquids taken for asthma 394.1
Choose the Following Pills or Liquids You Take
Slo-phyllin, Theo-24, Quibron, Slo-bid,
Theodur, Uniphyl, or other 395.1
Brethine, Bricanyl, Proventil, Ventolin,
Alupent, Metaprel, Terbutali 395.2
Other medications taken regularly 395.3
Do You Use Inhalers For Asthma?
Use of any inhalers 396.1
Use of Alupent, Proventil, Ventolin, Tornalate,
Brethair, Maxair, Bro 396.2
Use of Primatine, Bronkaid 396.3
Use of Atrovent 396.4
Use of Intal, Cromolyn 396.5
Use of Azmacort, Vanceril, Beclovent, Aerobid,
or other inhaled stero 396.6
Use of other inhalers 396.7
Use of Extender or spacer 396.8
Use of nebulizer with air compressor 396.9
Use of Alupent, Proventil, Ventolin, Brethine,
Bronkosol in nebulizer 396.10
Use of Atropine, Robinal in nebulizer 396.11
Use of Intal, Cromolyn in nebulizer 396.12
Use of other medications in nebulizer 396.13
How Often Forget Med
How often patient forgets to take medications 400.1
Complications From Medication
Difficulty sleeping 401.1
Shakiness 401.2
Heart palpitations 401.3
Headaches 401.4
Nervousness, moodiness, irritability 401.5
Hoarseness 401.6
Thrush or yeast infections 401.7
Problems Due to Expense of Medication
Problems due to expense of asthma medications 402.1
Do You Take Your Med for Asthma
Medications not taken due to cost 403.1
Do You Have a Pet?
Pets in home? 404.1
Do You Have a Peak Flow Meter?
Do you have a peak flow meter? 405.1
When is peak flow meter used 405.2
Is the peak flow meter helpful? 405.3
Adjust medications or call physician based
on peak flow readings 405.4
Do you know your personal best/normal pfm reading 405.5
Do You Smoke?
Do you smoke? 406.1
Are You Exposed to Significant Tobacco?
Exposed to significant tobacco smoke? 407.1
What Trigger Your Acute Asthma Attacks?
Pets in home 408.1
Cats, dogs, or other animals 408.2
Household dust 408.3
Pollens or certain seasons during the year 408.4
Aspirin 408.5
Foods 408.6
Exercise 408.7
Smoke, cold air, or other irritants 408.8
Exposure in Current Work Place Affects Your Asthma
Do you think exposure to something in your current work
place affects 410.1
Exposure to Something at Home Effect Your Asthma?
Do you think exposure to something in your home
effects your asthma? 411.1
Over the Past Year Has Your Asthma Gotten Better?
Improvement in asthma over past year 412.1
Does Asthma Affect the Quality of Your Life?
How much asthma effects quality of life 413.1
How Often Do You Have the Following Symptoms?
Cough 414.1
Sputum 414.2
Chest tightness 414.3
Wheezing or whistling sound in chest 414.4
Shortness of breadth 414.5
Heartburn 414.6
Have You Ever Had Allergic, etc...
Allergic rhinitis, hay fever, or nasal allergy 415.1
Hives 415.2
Eczema 415.3
Family members with asthma, hay fever, or eczema 415.4
Recurrent sinusitis 415.5
Nasal polyps 415.6
Worsening of asthma before periods or during
pregnancy 415.7
What Is Your Quality of Care For
Asthma Treatment?
Quality of care received for asthma last 3 months 416.1
Have You Had an Evaluation?
Evaluation done by: 417.1
Who Filled Out This Form?
Who filled out this form? 418.1
First You Have Seen This Patient For Asthma?
First time seen this patient for asthma 419.1
Convincing Clinical History?
Convincing clinical history of hyperactive
airways disease 420.1
Improvement of FEV1
Improvement of FEV1 > 15% with treatment 421.1
Response to Methacholine Challenge Test?
Response to methacholine challenge test 422.1
Fixed Obstructive Airway Disease
Patient with fixed obstructive airway disease 423.1
Indicating Patient's Asthma
Asthma severity 424.1
Level of control of asthma 424.2
Patient compliance with medication treatment 424.3
Patient compliance of suggested environmental changes 424.4
Patient understanding of asthma and treatment 424.5
Patient Has Used Systemic Steroid
Use of systemic steroid medications 429.1
Patient Hospitalized
Hospitalizations in past 6 months for asthma 430.1
Emergency Room Treatment for Asthma
Emergency room treatment for asthma last 6 months 431.1
Patient Asthma Medication History
Inhaled beta agonist 432.1
Oral beta agonist 432.2
Inhaled corticosteroid 432.3
Oral corticosteroid 432.4
Oral methylxanthine 432.5
Inhaled anticholinergic 432.6
Inhaled cromolyn 432.7
Nebulized beta anonist and anticholinergic 432.8
Patient Been Receiving Desensitization
Patient receiving desensitization treatments? 433.1
Patient Currently Manifest Complications Known
Steroids 434.1
Beta agonists 434.2
Theophylline 434.3
Beta blockers 434.4
What is Your Primary Specialty?
Physician's primary specialty 435.1
Certified or Board Eligible in This Specialty?
Physician's board certification in this specialty 436.1
Info From Physician
Info from physician 437.1
Satisfaction Again
A second set of questions 438.1
Relevance of Questions to Patient
How relevant were questions to patient? 443.1
Patient was able to answer questions accurately. 443.2
Time To Fill Out Questionnaire
Time to complete questionnaire 444.1
Patient Perception of Length of Forms
Patient perception of form length 445.1
Patient Response to Forms
Patients response to forms 446.1
Current Health Conditions
Congestive Heart Failure 447.1
Chronic lung disease 447.2
Blindness or trouble seeing 447.3
Deafness or trouble hearing 447.4
Sugar diabetes 447.5
Asthma 447.6
Ulcer or gastrointestinal bleeding 447.7
Arthritis or rheumatism 447.8
Sciatica or chronic back problem 447.9
History of Conditions
Hypertension 448.1
Angina 448.2
Heart attack or myocardial infarction 448.3
Stroke 448.4
Kidney disease 448.5
Cancer (excluding skin cancer) 448.6
People Living in Household
Number of adults living in household 449.1
Number of children living in household 449.2
Household Income
Household Income 450.1
Frequency of Hip Pain Limiting Activities
How often does hip pain limit your activities? 452.1
Frequency right hip limits activity 452.2
How Often Do You Have Stiffness?
Frequency stiffness, weakness limits activity - Left Hip 453.1
Frequency stiffness, weakness in right hip limits activity 453.2
Does Your Hip Limit Your Ability?
Degree left hip limits physical ability 454.1
Right hip limit recreational activities 454.2
Frequency of Hip Pain Limiting Sexual Activity
Left hip limits or interferes with sexual activity 455.1
Degree Right hip limits sexual activity 455.2
Does Your Hip Limit Your Ability to Work?
Left hip limits ability to work 459.1
Degree Right hip limits ability to work 459.2
How Much Pain Do You Have in Your Hip?
Perceived pain in Left hip 460.1
Perceived pain in right hip 460.2
When Does Your Hip Pain Bother You?
Conditions causing pain in left hip 461.1
Conditions causing pain in right hip 461.2
Past Four Weeks How Often Has Your
Hip Interfered
Past four weeks, how often has your hip
interfered with social intera 462.1
Extent right hip interfered with social
interaction over last 4 weeks 462.2
Hip Interfered With Your Sleep?
Frequency left hip interfered with your
sleep, last 4 weeks 463.1
Extent to which RH interfered with sleep over
last four weeks 463.2
Do You Have Difficulty Putting On Your Shoes?
Difficulty putting on your shoes and socks 464.1
Level of difficulty to put on shoes and socks 464.2
Describes How You Go Up Stairs?
Stairclimbing method 465.1
Best Describes How Your Go Down Stairs?
Best describes how you go down stairs? 466.1
Do You Have Difficulty Moving From a Sitting
To A Standing?
Ability to rise from sitting position 467.1
Ambulation - Type of Support Required
Support used when walking 468.1
Ambulation - Minutes Walked - Without Support
Duration able to walk without support 469.1
Ambulation - Minutes Walked - With Support
Walk with support 470.1
Ambulation - Degree of Limp - Without Support
Limp without support 471.1
Ambulation - Degree of Limp - With Support
Degree of limp with support 472.1
How Would You Describe Your Cigarette
Smoking?
Cigarette smoking habits 473.1
Satisfaction With Results of Hip Replacement
Level of satisfaction with the results of
hip replacement 474.1
Vision - Self Rating - Both Eyes
How would you rate your vision 476.1
Vision - Affect of Bright Light
How does bright light affect your vision 477.1
Vision - Self Rating, Right Eye
How would you rate the vision in your right eye 478.1
Vision Hinders Activity
Extent vision hinders from participating in
daily activities 479.1
Ability to recognize people and things across
the street 479.2
Extent ability to drive in daytime is hindered 479.3
Extent ability to drive at night is hindered 479.4
Extent ability to read street signs is hindered 479.5
Extent ability to see traffic lights is hindered 479.6
Extent ability to watch tv is hindered 479.7
Vision - Self Rating, Left Eye
How would you rate the vision in your left eye 480.1
Vision - Close-up Activities
Extent vision hinders from performing close-up
activities (reading) 481.1
Extent vision hinders from crafts & hobbies 481.2
Extent vision hinders reading labels in stores 481.3
Extent depth perception is limited 481.4
Sex
Sex 483.1
Occupation
Occupation: 484.1
Vision - Hindered by Glare
Extent glare limits participation in daily activities 493.1
Extent limited fr reading shiny paper 493.2
Extent hindered by sun, headlight glare when driving 493.3
Extent limited fr walking outside on a sunny day 493.4
Extent limited fr reading glare-y signs in supermarket 493.5
Expectation of Vision After Surgery
After surgery I expect my vision to be: 494.1
Expected Post-Operative Performance of
Usual Activ
Expected improvement in performance of usual daily
activities 495.1
Past Medical History of Patient
No known medical conditions 496.1
Cardiac disease 496.2
Diabetes requiring medical treatment 496.3
Hypertension 496.4
Past stroke 496.5
Autoimmune/rheumatoid disease 496.6
COPD 496.7
Mental illness 496.8
Cancer, excluding skin 496.9
Other conditions 496.10
No Eye Disease besides Cataract
No known eye disease besides cataract 497.1
No known OS disease besides cataract 497.2
Systemic Medications Taken by Patient
Patient currently not regularly medication 498.1
Patient taking aspirin 498.2
Patient taking insulin 498.3
Patient taking Coumadin 498.4
Patient taking steroids 498.5
NSAID 498.6
Other 498.7
Stage of Glaucoma Treatment
Procedures to treat OD glaucoma 499.1
Procedures to treat OS glaucoma 499.2
Laser trabeouloplasty treatment - glaucoma 499.3
OD past filtering surgery - glaucoma 499.4
OS no current treatment 499.5
OS topical therapy 499.6
OS laser trabeouloplasty 499.7
OS past filtering surgery 499.8
Other Eye Disease
Amblyopia 500.1
Other OD nerve disease 500.2
Previous cataract extraction and implant 500.3
History of cataract extraction and implant 500.4
OD significant eye trauma 500.5
OD chronic uveltis 500.6
OD diabetic retinopathy 500.7
OD macular degeneration 500.8
OD other significant problems 500.9
OS amblyopia 500.10
OS other optic nerve disease 500.11
OS previous cataract extract/implant 500.12
OS history of cataract extraction & implant 500.13
Significant OS trauma 500.14
OS chronic uveltis 500.15
OS diabetic retinopathy 500.16
OS macular degeneration 500.17
Other significant OS problems 500.18
Pupils
OD pupil 501.1
OS pupils 501.2
Amsler Grid
OD Amsler Grid 502.1
OS Amsler Grid 502.2
Corneal Examination
OD normal cornea 503.1
Guttata w/o edema 503.2
OD confluent guttata w/o edema 503.3
OD corneal edema 503.4
OD central corneal opacity 503.5
OD corneal dystrophy or degeneration 503.6
OD corneal interstitial keratitis 503.7
OD herpetic disease 503.8
OD other corneal pathology 503.9
OD previous corneal transplant 503.10
OD cornea cannot be assessed 503.11
OS normal cornea 503.12
OS corneal guttata w/o edema 503.13
OS corneal confluent guttata w/o edema 503.14
OS edema 503.15
OS central corneal opacity 503.16
OS corneal dystrophy 503.17
OS interstitial keratitis 503.18
OS herpetic disease 503.19
OS other corneal pathology 503.20
OS previous corneal transplant 503.21
OS cornea cannot be assessed 503.22
OS shallow cornea 503.23
OS cornea cannot be assessed 503.24
Anterior Chamber Findings
OD AC normal 504.1
OD AC flare only 504.2
OD AC cells only 504.3
OD AC keratic precipitates 504.4
OD AC posterior synechiae 504.5
OD pupil mydriatis 504.6
OD pupil irregular 504.7
OD shallow AC 504.8
OD transillumination defects 504.9
OD cannot assess 504.10
OS AC normal 504.11
OS AC flare only 504.12
OS AC cells only 504.13
OS keratic precipitates 504.14
OS posterior synechiae 504.15
OS pupil mydriasis 504.16
OS pupil irregular 504.17
OS shallow AC 504.18
OS transillumination defects 504.19
OS cannot assess anterior chamber 504.20
Predominant Lens Findings
Normal OD lens 505.1
Normal OS lens 505.2
Type of Cataract
Type of Cataract (nuclear, cortical, PSC, hypermature) 506.1
OS cataract type 506.2
OD cataract etiology 506.3
OS cataract etiology 506.4
Pseudophakia
OD P/C IOL 507.1
OS P/C IOL 507.2
OD A/C IOL 507.3
OS A/C IOL 507.4
OD posterior capsule opacification 507.5
OS posterior capsule opacification 507.6
OD posterior capsulotomy 507.7
OS posterior capsulotomy 507.8
Other Lens Findings
OD surgical aphakia 508.1
OS surgical aphakia 508.2
OD dislocated/subluxed crystalline lens 508.3
OS dislocated/subluxed crystalline lens 508.4
OD exfoliation syndrome 508.5
OS exfoliation syndrome 508.6
OD other lens findings 508.7
OS other lens findings 508.8
OD cannot assess lens 508.9
OS cannot assess 508.10
Optic Nerve (Note All Abnormalities)
Optic Nerve findings - OD 509.1
OS Nerve findings 509.2
OD C/D ratio - horizontal 509.3
OS C/D ratio - horizontal 509.4
OD C/D ratio - vertical 509.5
OS C/D ratio - vertical 509.6
Retina
OD normal retina 510.1
OS normal retina 510.2
OD macular edema 510.3
OS macular edema 510.4
Od macular hole 510.5
OS macular hole 510.6
OD epimacular membrane 510.7
OS epimacular membrane 510.8
Diabetic Retinopathy
OD diabetic retinopathy 511.1
OS Diabetic Retinopathy 511.2
OD proliferative diabetic retinopathy 511.3
OS proliferative diabetic retinopathy 511.4
OD vitreous hemorrhage 511.5
OS vitreous hemorrhage 511.6
OD prior laser therapy 511.7
OS prior laser therapy 511.8
OD prior vitrectomy 511.9
OS prior vitrectomy 511.10
Macular Degeneration
OD rare drusen 512.1
OS rare drusen 512.2
OD scattered drusen 512.3
OS scattered drusen 512.4
OD confluent drusen 512.5
OS confluent drusen 512.6
OD geographic atrophy 512.7
OS geographic atrophy 512.8
OD active subretinal NVM 512.9
OS active subretinal NVM 512.10
OD prior laser therapy 512.11
OS prior laser therapy 512.12
OD disciform scar 512.13
OS disciform scar 512.14
Retinal Detachment
OD current retinal detachment 513.1
OS current retinal detachment 513.2
OD prior retinal detachment surgical therapy 513.3
OS prior retinal detachment surgical therapy 513.4
OD current retinal break 513.5
OS current retinal break 513.6
OD prior surgical therapy 513.7
OS prior surgical therapy 513.8
Retinal Vascular Occlusion
OD BRVO 514.1
OS BRVO 514.2
OD CRVO 514.3
OD BRVO 514.4
OD BRAO 514.5
OS BRAO 514.6
OD CRAO 514.7
OS CRAO 514.8
Other Retinal Findings
OD other retinal findings 515.1
OS other retinal findings 515.2
Cannot assess OD retina 515.3
Cannot assess OS retina 515.4
Ocular Exam: Recent Visual Acuity
SC 516.1
CC 516.2
PH 516.3
MR w/in 3 months 516.4
Glare 516.5
PAM 516.6
Recent Visual Acuity - OS
SC 517.1
CC 517.2
PH 517.3
MR w/in 3 months 517.4
Glare 517.5
PAM 517.6
OD Recent Refraction
OD recent refraction, sign value, spherical 518.1
OD recent refraction, spherical (hundredths) 518.2
OD recent refraction, sign for cylindrical value 518.3
OD recent refraction, cylindrical (hundredths) 518.4
OD recent refraction, axis 518.5
Operated Eye
Operated eye 519.1
Operation Type
Cataract operation type 520.1
Total time, (tenths of minutes) 520.2
Power (tenths) 520.3
Acetabular Graft Data
Acetabular graft type 521.1
Acetabular Graft source - Femoral head 521.2
Acetabular Graft source - Femur 521.3
Acetabular Graft source - Freeze dried 521.4
Acetabular Graft source - Local 521.5
Acetabular Graft source - Iliac Crest 521.6
Acetabular Graft source - Structural 521.7
Acetabular Graft source - Other 521.9
Acetabular Graft source - Morselized 521.10
Acetabular Graft location - Superior 521.11
Acetabular Graft location - Medial 521.12
Acetabular Graft location - Posterior 521.13
Acetabular Graft location - Anterior 521.14
Acetabular Bone Defects Found Intra-Operatively
Acetabular Bone defects - Contained Anterior 522.1
Acetabular Bone defects - Contained Superior 522.2
Acetabular Bone defects - Contained Posterior 522.3
Acetabular Bone defects - Contained Medial 522.4
Acetabular Bone defects - Segmental Anterior 522.5
Acetabular Bone defects - Segmental Superior 522.6
Acetabular Bone defects - Segmental Posterior 522.7
Acetabular Bone defects - Segmental Medial 522.8
Acetabular Bone defects - Central 522.9
Acetabular Bone defects - Pelvic Discontinuity 522.10
Intraop Blood Transfusions
Intraoperative Blood transfusions - Autologous Blood 523.1
Intraoperative Blood transfusions - Bank Blood 523.2
Surgical Time
Elapsed time of surgery 524.1
Anesthesia
Cataract surgery anesthesia 525.1
Duration of Procedure
Total duration of cataract procedure 526.1
Intraocular Lens Type
Intraocular lens type 527.1
IOL irrigation 527.2
Visco-elastic IOL 527.3
Antibiotic Coverage
Erythromycin 528.1
Velosef usage 528.2
Other antibiotics usage 528.3
Subconjunctival Gentamycin 528.4
Steroid Treatment
Use of Kenalog 529.1
Use of Hexadrol 529.2
Weeks of topical steroid use 529.3
Weeks of topical steroid use 529.4
Location of Incision
Millimeters from limbus 530.1
Quadrant of incision 530.2
Type of incision 530.3
Desired Spherical Equivalent Refraction
Desired spherical refraction (hundredths) 531.1
Desired spherical refraction to the hundredths 531.2
Intraoperative events
Intraoperative events 532.1
Retrobulbar hemorrhage 532.2
Vitreous loss 532.3
Choroid hemorrhage 532.4
Loss of nuclear fragment 532.5
Significant residual cortical material 532.6
Residual posterior capsule opacity 532.7
Broken capsule 532.8
Zonule dehiscence 532.9
Retinal break 532.10
Retinal detachment 532.11
IOL malposition 532.12
Other interoperative events 532.13
Other interoperative events 532.14
Dilated Pupil Size (mm) at Commencement
of Surgery
Dilated pupil size at commencement of surgery in mm 533.1
Cord Incision Length
Cord incision length in mm 534.1
Size of Capsulectomy
Size of capsulectomy in mm 535.1
Continuous tear capsulorrhexis 535.2
Can-opener capsulorrhexis 535.3
Other capsulorrhexis 535.4
Meri?? extension of capsul?? 535.5
OS Recent Refraction
OS recent refraction, sign value 536.1
OS recent refraction, spherical (hundredths) 536.2
OS recent refraction, sign of cylindrical value 536.3
OS recent refraction, cylindrical (hundredths) 536.4
OS recent refraction, axis 536.5
Intraocular Pressure
OD intraocular pressure 537.1
OS intraocular pressure 537.2
OD K Readings
OD K1 readings, spherical (hundredths) 538.1
OD K2 readings, cylindrical, (hundredths) 538.2
OD K readings, axis 538.3
K Readings - OS
OS K1 readings, spherical, (hundredths) 539.1
OS K2 readings, cylindrical, (hundredths) 539.2
OS K readings, axis 539.3
Axial Length
OD axial length, (hundredths) 540.1
OS axial length (hundredths) 540.2
Corneal Edema
Corneal epithelial edema 542.1
Stromal K edema 542.2
Folds decemet 542.3
Wound Status
Normal 543.1
Broken suture 543.2
Leak present 543.3
Filtering blebs 543.4
Choroidal hemorrhage 543.5
Anterior Chamber
Cell, anterior chamber 544.1
Flare, anterior chamber 544.2
Vitreous present in AC 544.3
Hyphema 544.4
Endophthalmitis 544.5
Pupil Exam Items
Normal pupil characteristics 545.1
Mydriatic pupil > 4mm 545.2
Irregular pupil 545.3
Pupillary block 545.4
Other pupil characteristics 545.5
Intraocular Lens Dislocation
IOL dislocation 546.1
IOL dislocation length 546.2
Optically significant 546.3
Optically significant 546.4
Posterior Capsule
Clear posterior capsule 547.1
Visually significant opacity 547.2
Retained cortex 547.3
S/P yag or surgical capsulotomy 547.4
Pitting of lens 547.5
Optic Nerve
Status of optic nerve 548.1
OD horizontal cup to disk ratio to the hundredths 548.2
OS horizontal C/D ratio, to the hundredths 548.3
OD vertical CD ratio (hundredths) 548.4
OS vertical C/D ratio 548.5
Post-op Fundus Findings
Same as pre-op 549.1
Uncovered pre-op disease 549.2
New post-op disease 549.3
CME 549.4
Filtering blebs 549.5
Choroidal detachment 549.6
Epimacular membranes 549.7
Retinal break since surgery 549.8
Retinal detachment since surgery 549.9
Suture Lysis Performed, Date
Suture lysis performed 550.1
Month of suture lysis 550.2
Day of suture lysis 550.3
Year of suture lysis 550.4
Day of suture lysis 550.5
Year of yag capsulotomy 550.6
Month of yag capsulotomy 550.7
Day of yag capsulotomy 550.8
Year of yag capsulotomy 550.9
Month of eyeglass Rx 550.10
Day of eyeglass Rx 550.11
Year of eyeglass Rx 550.12
Year of eyeglass Rx 550.13
Intraocular Pressure
Intraocular pressure 551.1
Status of glaucoma 551.2
IOP 551.3
Visual Acuity
SC 552.1
CC 552.2
PH 552.3
MR 552.4
PAM 552.5
Near vision with correction 552.6
Refraction
Sign for spherical value 553.1
Spherical value (hundredths) 553.2
Sign of cylindrical value 553.3
Cylindrical (hundredths) 553.4
Axis 553.5
Change in Vision
Significant change in vision 554.1
Macular degeneration 554.2
Glaucoma 554.3
Optic nerve disease 554.4
Diabetic retinopathy 554.5
Other 554.6
Perioperative IOP
Perioperative IOP - day 1 555.1
Final day, perioperative IOP 555.2
Perioperative IOP - day n 555.3
Patient Satisfaction With Results of Surgery
Patient satisfaction with results of surgery 556.1
Patient's Willingness to Repeat
Patient willing to undergo same procedure 557.1
Iris Color
OD iris color 558.1
OS iris color 558.2
Visual Field Loss
OD mild visual field loss 559.1
OD mod visual field loss 559.2
OD severe visual field loss 559.3
OS mild visual field loss 559.4
OS moderate visual field loss 559.5
OS severe visual field loss 559.6
Pupils - Additional
OD mydriatis > 4mm 560.1
OD irregular pupils 560.2
OS mydriatis > 4mm 560.3
OS irregular pupil 560.4
Intraocular Lens Decentralization
Intraocular lens decentralization - OD 561.1
Intraocular lens decentralization - OS 561.2
Alternative Version - Visual Field Loss
OD visual field loss 562.1
OS visual field loss 562.2
Etiology of Cataract
Etiology of Cataract
(nuclear, cortical, PSC, hypermature) 601.1
OS cataract etiology 601.2
Cup to Disc Ratio
OD C/D ratio - horizontal (hundredths) 602.1
OS C/D ratio (hundredths) 602.2
OD C/D ratio - vertical (hundredths) 602.3
OS C/D ratio - vertical (hundredths) 602.4
Retinal Break
OD current retinal break 603.1
OS current retinal break 603.2
OD retinal break prior surgical therapy 603.3
OD retinal break prior surgical therapy 603.4
Intraocular Irrigation
IOL irrigation 604.1
Visco-elastic
Visco-elastic 605.1
Yag Capsulotomy Performed
Yag capsulotomy 606.1
Month of yag capsulotomy 606.2
Day of yag capsulotomy 606.3
Year of yag capsulotomy 606.4
Eyeglass RX
Eyeglass Rx written 607.1
Month of eyeglass Rx 607.2
Day of eyeglass Rx 607.3
Year of eyeglass Rx 607.4
Type of Suture
Type of suture 633.1
Employment Status - Attributed to Vision
Current employment status of patient 634.1
Time it Took to Reach Current Vision Status
Patient - Time it took to reach current vision status 635.1
Energy, Fatigue, Emotional Status Items
Did you feel full of pep? 694.1
Have you been a nervous person? 694.2
Have you felt so down nothing could cheer you? 694.3
Have you felt calm and peaceful? 694.4
Did you have a lot of energy? 694.5
Have you felt downhearted and blue? 694.6
Did you feel worn out? 694.7
Have you been a happy person? 694.8
Did you feel tired? 694.9
Social Function During Past Four Weeks
Physical health/emotional problems interfered with social 695.1
APPENDIX 7.B (Normative) TEST/OBSERVATION MASTER SEGMENTs (OMx)
These segments define the format for the general information about the
observations that a clinical or diagnostic service produces and sends to its
"clients." This format can be used to send the producer's entire
test/observation definition or a few of the producer's observations, such as
those with procedure, technique, or interpretation changes.
In anticipation of an object-oriented organization of segments in future
releases of this standard, the attributes of observations/batteries have been
grouped into six different segments:
OM1 contains attributes that apply to all observations
OM2 applies to numerically-valued observations
OM3 applies to text or code-valued observations
OM4 applies to observations or batteries that require specimens
OM5 contains attributes of batteries, or sets of observations or other
batteries
OM6 contains quantities (observations in a most general sense) that are
calculated from one or more other observations
Thus, the full definition of a numerically-valued laboratory observation would
require the transmission of OM1, OM2, and OM4.
In the following discussion, we use OMx to refer to any of the six
observation-defining segments. Each instance of an OMx segment contains
information about one observation or observation battery. These OMx segments
are designed to be "inclusive" and accommodate the attributes of many kinds of
observations. Thus, the fact that a field is listed in a particular segment
should not be construed as meaning that a producer must include information
about that item in its definition transmission. Many fields will apply to some
terms; others will not. One observation producer may choose to populate one
set of fields; another may choose to populate a different set of fields,
according to the requirements of that producer's "client."
Most of the fields of data type TX in those segments are intended to include
information typically contained in a diagnostic service's user manual. Such
fields should describe how the data is to be interpreted or used, and are not
intended for computer interpretation.
One or more observation definition segments (OMx) may be included in any
message, but they should immediately follow the MSH segment and precede any
other kinds of segments except the error (E) segment in the message.
Remember that the magnitude of a treatment can also be regarded as an
observation and, as such, can be represented as an observation within these
segments. Many examples exist. When a blood gas is transmitted, the
requesting service usually transmits the amount of inspired O2 (a treatment) on
requisition. (In an electronic transmission, the service would send this as an
OBX segment, along with the electronic order for the test.) When blood levels
are drawn, the amount and time of the last dose are routinely included as
observations on the request for service. A pharmacy system could routinely
send to a medical record system the average daily dose of each outpatient
medication it dispenses. In such cases, the treatment amounts would be
observations to the receiving system and would be transmitted as OBX segments.
When received, they would be treated like any other observation. A medical
record system could then create, for example, a flowchart of lab results, or
lab results mixed with relevant treatments.
The message structure is as follows:
MSH
{ OM1
[ other segments(s) ]
}
where other segments can be any of the following combinations:
[
[ OM2 ]
[ OM3 ]
[ OM4 ]
]
or
[ OM3
[ { OM4 } ]
]
or
[ OM5
[ { OM4 } ]
or
[ OM6
OM2 ]
Note: A result may have both an OM2 (numeric) and OM3 (categorical) segment included in case the value may be either numeric and/or categorical. |
The OM1 segment contains attributes that apply to the definition of most
observations. This segment also contains the field attributes that specify
what additional segments might also be defined for this observation.
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
ITEM# |
ELEMENT NAME |
1 |
3 |
ST |
R |
|
|
00585 |
Segment
Type ID |
7.B.3.1.0 OM1 field definitions
Definition: the string OM1 - identifies a record as a general observation
definition segment.
Definition: the first OM1 segment in a message is described as 1, the second
as 2, and so on.
Components: <identifier> ^ <text> ^ <name of coding
system>^ <alternate identifier> ^ <alternate text> ^ <name of
alternate coding system>
Definition: the producer's usual or preferred identification of the test or
observation. Only three components should be included: <ID
code>^<service text name/description>^<source list of code>.
All components should be non-null. The source list may be any of those
included in ASTM Tables 3 and 5, or a local code.
Definition: the allowed data type(s) for this observation. The codes are the
same as those listed OBX (a given observation may, under different
circumstances, take on different data types). Indeed, under limited
circumstances, an observation can consist of one or more fragments of different
data types. When an observation may have more than one data type, e.g., coded
(CE) and numeric (NM) the allowable data types should be separated by repeat
delimiters. Refer to table 0125 - value type for valid values.
Definition: a flag indicating whether or not at least one specimen is
required for the test/observation. Refer to table 0136 - Y/N indicator
as defined in Chapter 2.
Y one or more specimens are required to obtain this observation
N a specimen is not required
When a specimen is required, segment OM4 will usually be included (one per
specimen is required).
Definition: uniquely identifies the service producing the observation
described in this segment. Three components should be included: an
identifying code, the name of the producer, and the identity of the coding
system (e.g., 323-5678^Acme Special Lab^MC). The identity of the coding system
will usually be MC (Medicare provider number or HIBCC site codes) in the United
States. Each country may want to specify its preferred coding system and
define a coding system ID to identify it.
Remember that the magnitude of a treatment or the setting on a machine, such
as a ventilator, can be regarded as an observation. Thus, pharmacy,
respiratory care, and nursing may be producers of such observations.
Definition: a text description of this observation.
Definition: lists all alias codes/identifiers for this observation. If more
than one alias code needs to be specified, multiple three-component, CE-format
entries (<code 1>^<name 1>^<code system 1>) may be given,
separated by repeat delimiters. An observation may have as many names/codes as
are applicable (e.g., ICD9, ACR-NEMA, SNOMED, and READ). We encourage the
inclusion of as many different codes as may apply to assist cross-system
mapping of terminology. All components of each triplet should be non-null
(that is, names and coding system IDs within the CE data type are required in
addition to codes). The source list may be any of those included in ASTM
Tables 3 and 5.
Because the size (dose) of a treatment can also be an observation, codes that
identify treatments (e.g., NDC, ICCS) may also be included in this field.
Note: In this field, the names within the CE data type are required. |
Definition: include any text aliases, or synonyms for the name in the context
of the ordering service. These are alternative names, not associated with a
particular coding system, by which the battery, test, or observation (e.g.,
measurement, test, diagnostic study, treatment) is known to users of the
system. Multiple names in this list are separated by repeat delimiters.
Definition: the preferred name for reporting the observation or battery. The
name can contain up to 30 characters (including blanks). It is the preferred
name for columnar reports that require a maximum name size.
Definition: a name that can be used in space-limited reports (e.g., specimen
labels) to identify the observation for the convenience of human readers. The
name can contain up to eight characters.
Definition: the fully specified name for the observation or battery. It may
include the full (unabbreviated) multiple-word names and contain up to 200
characters. It should be as scientifically precise as possible.
Definition: whether or not a test/observation is an orderable code. Refer
to table 0136 - Y/N indicator as defined in Chapter 2.
Y the test/observation is an orderable code
N the test/observation is not orderable
For example, blood differential count is usually an orderable "test." MCV,
contained within the differential count, is usually not independently orderable.
Definition: when applicable, specifies the instrument or device that is used
to generate this observation or battery. Examples are the automated instrument
in the laboratory, the imaging device and model number in radiology, and the
automatic blood pressure machine on the ward. The instrument is specified as a
coded entry in anticipation that these identifiers could be specified as codes.
Initially, we expect that most of the information about devices will be
transmitted as text in the second component of the CE identifier. If more than
one kind of instrument is used, all of them can be listed, separated by repeat
delimiters.
Definition: method(s) used to produce the observation should be recorded in a
computer-understandable (coded) form here. This field should report the same
method(s) reported in narrative in the following field. More than one method
may be listed, but only if they produce results that are clinically
indistinguishable. Multiple methods must be separated by repeat delimiters.
Definition: whether or not a portable device may be used for the
test/observation. Refer to table 0136 - Y/N indicator as defined in
Chapter 2.
Y the observation can be obtained with a portable device brought to the
patient
N the patient or specimen must be transported to the device.
Definition: permits the sorting of observation orders and values by the
providing service's department/section. It provides "source oriented"
reporting when required. The codes for this field should be taken from ASTM
Table 15 (Diagnostic Service Codes). Free text may be used instead of these
codes, but in that case, they should be recorded as the second "component" of
the field to distinguish them from the standard codes. Multiple codes in this
field are separated by repeat delimiters.
Definition: the telphone number for calling responsible parties in this
section to ask results or advice about the use of this test.
Definition: whether the definition entry identifies a test battery, an entire
functional procedure or study, a single test value (observation), multiple test
batteries or functional procedures as an orderable unit (profile), or a single
test value (observation) calculated from other independent observations. The
possible options are the following:
Value |
Description |
P |
Profile or battery consisting of many independent atomic observations (e.g., SMA12, electrolytes), usually done at one instrument on one specimen |
F |
Functional procedure that may consist of one or more interrelated measures (e.g., glucose tolerance test, creatine clearance), usually done at different times and/or on different specimens |
A |
Atomic test/observation (test code or treatment code) |
S |
Superset--a
set of batteries or procedures ordered under a single code unit but processed
as separate batteries (e.g., routines = CBC, UA, electrolytes) |
C |
Single observation calculated via a rule or formula from other independent observations (e.g., Alveolar--arterial ratio, cardiac output) |
Codes P, F, and S identify sets (batteries) and should be associated with an
OM5 segment that defines the list of elements. The definitions for the
contained elements would have to be sent in other independent OMx segments, one
for each contained element. In the ASTM context, most text reports--such as
discharge summaries, admission H&Ps, and chest x-ray reports--are
considered as sets, in which each section of the report (e.g., description,
impression, and recommendation of an x-ray report) is considered a separate
observation.
Code A identifies a single direct observation and would usually be associated
with an OM2 and/or OM3 segments.
Code C identifies a derived quantity and would usually be associated with an
OM6 segment.
All of these codes can be associated with one or more OM4 (specimen) segments.
Definition: an optional string that defines the preferred header under which
this observation should be listed on a standard display. For example, if the
test is hemoglobin, this string might be "Complete blood count." It is
represented as a coded data type so that a battery can be a header. Only the
description part of the string may be included in case the subheader does not
have an associated code. When a series of observations is displayed according
to the sort order given below, the subheader that groups those observations is
presented whenever the subheader changes.
Definition: an optional string that defines the sort order in which this
observation is presented in a standard report or display that contains many
observations.
Definition: the date and time that the last of any field change was made and
in the host's record corresponding to the OM1 segment.
Definition: the date and time of the last change in the test procedure that
would make previous results incompatible with new results, e.g., the last time
that normal reference range or units changed for a numeric test/observation.
We strongly suggest that observation producers never use the same observation
ID when the measurement procedures changes in such a way that results produced
under the new procedure are clinically different from those produced with the
old procedure. Rather the producer should try to adjust the new procedure so
that its values are clinically indistinguishable from the old. Failing that,
one should create a new observation ID for the observation produced under the
new procedure.
In the rare circumstances when a procedure change occurs and neither of the
above two options are viable, this field shall be used to transmit the
effective date-time of the new procedure. The receiving system shall assume
that any values that come across under this observation ID are under the new
procedure after this date and take appropriate steps to distinguish the old
from the new observations.
This number is included to provide a means of communicating with the
observation producing service when they have questions about particular
observations or results.
Definition: typical processing time for single test/observation. This field
indicates the time from the delivery of a specimen or transport of a patient to
a diagnostic service and the completion of the study. It includes the usual
waiting time. The units are measured in minutes.
Definition: usual length of time (in minutes) between the start of a test
process and its completion.
Definition: specifies one or more available priorities for performing the
observation or test. This is the priority that can be placed in
OBR-28-quantity/timing. For tests that require a specimen, this field
may contain two components in the format <specimen
priority>^<processing priority>. The first component in this case
indicates the priority with which the specimen will be collected and is the
priority that is specified in an OBR segment when ordering the observation.
The second component indicates the corresponding priority with which the
producer service will process the specimen, produce the observation, and return
results, when this differs from collection priority. Permitted priority values
are the following:
Value |
Description |
S |
Stat
(do immediately) |
The priority for obtaining the specimen is included in OM4. Multiple
priorities may be given, separated by repeat delimiters. For example,
S~A~R~P~T indicates that the test may be ordered using codes S, A, R, P, or T.
Definition: the available priorities reporting the test results when the user
is asked to specify the reporting priority independent of the processing
priority. The available codes are:
Value |
Description |
C |
Call
back results |
Definition: if an outside service or services produce the observation, this
field contains the identification(s) of the outside service(s). The format of
this CE field uses the producer ID (as defined in OM1-6-producer ID) and
the name of the service separated by component delimiters. An example is
39221^ACME lab^MC. If multiple services are used, they should be separated by
repeat delimiter(s).
Definition: record in this field the address of the outside services listed
in OM1-28-outside site(s) where observation may be performed. If
multiple services are recorded in that field, their addresses should be
separated by repeat delimiters, and the addresses should appear in the same
order in which the services appear in the preceding field.
Definition: the telephone number of the outside site.
Definition: the degree to which special confidentiality protection should be
applied to the observation. For example, a tighter control may be applied to
an HIV titer than to a CBC. Refer to user-defined table 0177 -
confidentiality code for suggested values.
Value |
Description |
V |
Very
restricted |
Definition: list of variables that the diagnostic service needs to interpret
the results of an ordered study. The observations specified here should be
sent to the diagnostic service as OBX segments along with the order (OBR)
segment.
Example for cervical pap smear:
2000.32^date last menstrual period^AS4~2000.33^menstrual state^AS4
Example for arterial blood gas:
94700^inspired 02^AS4
These examples use AS4 codes in code/text format to identify the variables.
Separate multiple items by repeat delimiters.
Definition: clinical information about interpreting test results. Examples
are the conditions (drugs) that may cause false abnormals, and the information
about the sensitivity and specificity of the test for diagnoses.
Definition: list diagnosis or problem for which the test is a
contraindication or of possible danger (e.g., pacemaker, pregnancy, diabetes).
For example, if the test identified in OM1 was an intravenous pyelogram, this
field would include warnings about the use of contrast media in diabetes. The
contraindication diagnoses should be separated by repeat delimiters.
Most contraindication rules will be transmitted as free text. In such cases,
the contents serves only as information for human reading. However, an
alternative for machine readable contraindication rules also exists. The rule
may be defined formally in the Arden syntax (ASTM 1460-1992) which has syntax
for defining algebraic and transcendental equations, as well as temporal and
logical selection criteria based on patient information stored in the computer
record. Reflex rules that are written in Arden Syntax should begin and end with
a double semi-colon (;;), the Arden slot delimiter.
Definition: includes the test names as type CE (i.e., <code>^<text
name>^<coding system>) that may be ordered automatically by the
diagnostic service, depending on the results obtained from the ordered battery.
A screening CBC might trigger a reticulocyte count if the Hgb is less than 12.
Multiple reflex tests are separated by repeat delimiters.
Definition: the rules that trigger the reflex tests listed above. If
multiple reflex tests are listed in OM1-35-reflex tests/observations
separated by repeat delimiters, a set of corresponding rules will be included
in this section. The first rule will apply to the first test, the second to
the second test, and so on.
Most reflex rules will usually be transmitted as free text. In such cases,
the contents serves only as information for human reading. However, an
alternative for machine readable rules also exists. The rule may be defined
formally in the Arden syntax (ASTM 1460-1992) which has syntax for defining
algebraic and transcendental equations, as well as temporal and logical
selection criteria based on patient information stored in the computer record.
Reflex rules that are written in Arden Syntax should begin and end with a
double semi-colon (;;), the Arden slot delimiter.
Definition: codes and a fixed text message that is always associated with an
abbreviation. The field may include multiple messages separated by repeat
delimiters.
Most rules about patient testing will be transmitted as free text. In such
cases, the contents serves only as information for human reading. However, an
alternative for machine readable rules also exists. The rule may be defined
formally in the Arden syntax (ASTM 1460-1992) which has syntax for defining
algebraic and transcendental equations, as well as temporal and logical
selection criteria based on patient information stored in the computer record.
Rules about patient preparation are written in Arden Syntax should begin and
end with a double semi-colon (;;), the Arden slot delimiter.
Definition: for tests or observations that require special patient
preparation, diet, or medications, record them here. For GI contrast studies,
this field would contain the pretest diet, e.g., low residue for two days, NPO
before study, and the preferred purgatives. Each separate med, diet, or
preparation should be delimited by a repeat delimiter. Separate each
requirement by a repeat delimiter. Example for a sigmoidectomy: clear liquid
diet full day before procedure~take 8 oz mag citrate 6pm day before
procedure~take 2 ducat tabs (5m) at 4pm day before procedure~NPO past midnight.
Definition: treatments that may be needed as part of the procedure. Examples
are radioactive iodine for a thyroid screen, and methacholine for a
methacholine spirometry challenge. This field should be identified as a CE
data type.
Definition: text description of the foods, diagnoses, drugs, or other
conditions that may influence the interpretation of the observation.
Information about the direction of the effect, and any recommendation about
altering the diet, conditions, or drug before initiating the test
observation.
Most rules about factors that effect the test interpretation will be
transmitted as free text. In such cases, the contents serves only as
information for human reading. However, an alternative for machine readable
rules also exists. The rule may be defined formally in the Arden syntax (ASTM
1460-1992) which has syntax for defining algebraic and transcendental
equations, as well as temporal and logical selection criteria based on patient
information stored in the computer record. Rules about patient preparation are
written in Arden Syntax should begin and end with a double semi-colon (;;), the
Arden slot delimiter.
Definition: for diagnostic studies/tests that are performed only at certain
times during the course of a work day or work week, this field indicates the
maximum interval between successive test performances (the test may actually be
performed more frequently). The format given in ASTM Table 17, Codes for
Service Intervals, should be used. If necessary, multiple codes may be given,
separated by repeat delimiters. The use of multiple codes indicates that the
test is performed at multiple concurrent intervals. For example, Q6H indicates
that the test is performed at least once every 6 hours around the clock. Q1J
indicates that the test is performed at least every week on Mondays. QAM~QPM
indicates that the test is performed at least once every morning and every
evening. Q1J~Q3J~Q5J indicates that the test is performed at least every week
on Mondays, Wednesdays, and Fridays. C indicates that the test is performed
continuously, 7 days per week.
Definition: text description of the methods used to perform the text and
generate the observations. Bibliographic citations may be included.
This segment contains attributes of observations with continuous values
(including those with data types of numeric, date, or time stamp). It can be
applied to observation batteries of type A and C (see OM1-19-nature of
test/observation).
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
ITEM# |
ELEMENT NAME |
1 |
3 |
ST |
R |
|
00585 |
Segment
Type ID |
7.B.4.1.0 OM2 field definitions
Definition: the string OM2 - identifies a record as a numeric observation
segment.
Definition: the same value as the sequence number of the associated OM1
segment.
Definition: for single tests/observations (those with a nature code of A
or C, as described in OM1-19-nature of test/observation) that have
numeric values, this field contains their customary units of measure.
Definition: used for numerically valued single observations (code A or C
as described in OM1;15), specifies the total length in characters of the field
needed to display the observation, and the number of digits displayed to the
right of the decimal point. This is coded as a single number in the format
<length>.<decimal-digits>. For example, a value of 6.2 implies 6
characters total (including the sign and decimal point) with 2 digits after the
decimal point. For integer values, the period and <decimal-digits>
portion may be omitted (that is, 5.0 and 5 are equivalent). More than one such
mask may be transmitted (separated by repeat delimiters) when it is necessary
to define multiple display formats that are possible.
Definition: for single tests/observations - the corresponding SI units of
measure in the format, when these differ from the customary units of measure
given in the previous field.
Definition: for continuous, numerically valued tests/observations, with a
nature code of A or C (see OM1-19-nature of test/observation). This is
a factor for converting the customary units to SI units.
In the case that the observation units are not SI units, this fields
provide the formula needed to convert from the reported units to SI units, this
shall include the equation needed to convert from the reporting to the SI
units.
In the case that the relation is simply multiplicative, this field shall
include only the conversion factor. E.g., if (results SI units) = c * (results
reporting units). Then only c would be stored in this field. In the case of
any other functional relationship, the entire equation would be stored as a test.
Definition: provides reference (normal) ranges for "numeric"
observations/tests with a nature code of A or C (see OM1-19-nature of
test/observation). It can identify different reference (normal) ranges for
different categories of patients according to age, sex, race, and other
conditions.
The general format is
<ref. (normal) range1>^<sex1>^<age
range1>^<age
gestation1>^<species1>^<race/subspecies1>^<text
condition1>~
<ref. (normal) range2>^<sex2>^<age
range2>^<age
gestation2>^<species2>^<race/subspecies2>^<text
condition2>~
·
·
·
<ref. (normal) rangen>^<sexn>^<age
rangen>^<age
gestationn>^<speciesn>^<race/subspeciesn>^<text
conditionn>
The components are defined in the following sections.
The format of this component is <low value & high value>, where
the range is taken to be inclusive (i.e., the range includes the end points).
In this specification, the units are assumed to be identical to the reporting
units given in OM2-3-units of measure).
The sex of the patient.
The age range (in years or fractions thereof) is specified as two values
separated by a subcomponent delimiter (i.e., <low value & high
value>) in order to allow a simple and consistent machine interpretation of
this component. Ages of less than one year should be specified as a fraction
(e.g., 1 month = 0.0830, 1 week = 0.01920, 1 day = 0.0027300). However, for
most purposes involving infants, the gestational age (measured in weeks) is
preferred. The lower end of the range is not indicated; the upper end is,
assuring that series of ranges do not overlap.
The gestational age is relevant only when the reference range is influenced
by the stage of pregnancy. A range of values separated by a component
delimiter is required, i.e., <low value & high value>. The
gestational age is measured in weeks from conception. For example,
<1&10> implies that the normals apply to gestational ages from 1 week
to 4 weeks inclusive (1&4). The lower end of the range is not included;
the upper end is, assuring that series of age ranges do not overlap.
This field is assumed to be human unless otherwise stated. The species
should be represented as text (e.g., rabbit, mouse, rat).
In the case of humans (the default), the race is specified when race
influences the reference range. When normal ranges for animals are being
described, this component can be used to describe subspecies or special breeds
of animals.
The condition is simply free text. This component allows for definition of
normal ranges based on any arbitrary condition, e.g., phase of menstrual cycle
or dose of a particular drug. It is provided as a way to communicate the
normal ranges for special conditions. It does not allow automatic checking of
these text conditions.
A range that applies unconditionally, such as albumin, is transmitted
as:
3.0 & 5.5
A normal range that depends on sex, such as Hgb, is transmitted
as:
13.5 & 18^M~
12.0 & 16^F
A normal range that depends on age, sex, and race (a concocted example)
is:
10 & 13 ^M^0 & 2 ^^^B
11 & 13.5 ^M^2 & 20 ^^^B~
12 & 14.5 ^M^20 & 70 ^^^B~
13 & 16.0 ^M^70 & ^^^B
When no value is specified for a particular component, the range given
applies to all categories of that component. For example, when nothing is
specified for race/species, the range should be taken as the human range
without regard to race. If no age range is specified, the normal range given
is assumed to apply to all ages. If the upper or lower end of a range is left
out, it is assumed to be +infinity or -infinity, respectively.
When two different methods result in two different reference ranges, two
different observations and corresponding OMx segments should be defined.
Definition: applies only to single tests/observations (i.e., a nature code
of A or C, as described in OM1-19-nature of test/observations) with
numeric results. When a critical range is defined for such observations, it
should be recorded here in the same format as the normal range (see
OM2-7-reference (normal) range-ordinal and continuous obs).
Components: <range> ^ <numeric change> ^ <%/a change> ^
<days>
Definition: applies only to single tests/observations with a nature code
of A or C (see OM1-19-nature of test/observation). It defines the range
of possible results. Results outside this range are not possible. The field
should be recorded in the same format as the normal and critical ranges.
Definition: applies to numeric tests/observations with a nature code of A
or C (see OM1-19-nature of test/observation). The field describes the
information that controls delta check warnings and includes four
components.
1) The range to which the following applies: <low &
high>
All the ranges are defined in terms of the customary reporting units given
in OM2-3-units of measure. If no value range is given, the check
applies to all values.
2) The numeric threshold of the change that is detected, e.g., 10
3) Whether the change is computed as a percent change or an absolute
change. This component can have two possible values:
% Indicates a percent change
a Absolute change
4) The length of time that the service retains a value for computing
delta checks. This is recorded in number of days.
More than one delta check rule can apply.
13&16^10^%^100~16.1&20^2^a^100 implies that the delta check will
trigger on a 10% change when the value of the observation is between 13 and 16.
The check will trigger on an absolute change of 2 when the value is between
16.1 and 20. In both cases, the system will keep the last result for 100 days.
In this example, beyond 100 days, the computer will not compute a delta check
because it will not have a comparison value.
Definition: used for numerically valued single observations (a nature code
of A or C, as described in OM1-19-nature of test/observation) and
specifies the smallest meaningful difference between reported values (the
effective resolution of the measuring instrument or technique for continuous
data, or the smallest discrete interval that can occur for discrete
data).
This segment applies to free text and other non-numeric data types.
|
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
ITEM# |
ELEMENT NAME |
1 |
3 |
ST |
|
00585 |
Segment
Type ID |
7.B.5.1.0 OM3 field definitions
Definition: the string OM3 - identifies a record as a categorical
test/observation segment.
Definition: the same value as the sequence number of the associated OM1
segment.
Definition: for observations whose categorical responses are taken from a
specified table of codes (e.g., CE data types), record the preferred coding
system for this observation (e.g., ICD9, SNOMED III). Take the codes from ASTM
Table 3 or 5, or specify a local code.
Definition: in the case that the list of coded answers is easily
enumerated, list the valid coded answers for this observation here using the
preferred coding system given in OM3-3-preferred coding system. If for
example, the given observation was VDRL, the valid answers might be
non-reactive, 86^ intermediate, and 87^ reactive.
Definition: certain observations/tests with a nature code of A or C (see
OM1-19-nature of test/observation) have text (alpha) results (e.g.,
reactive, nonreactive). Alpha normals for those tests should be entered in
this field (e.g., "nonreactive").
The format of this field is:
The first component is a code taken from a standard code source list. The
second component is the text associated with the code. The third component is
the identification of the code table source. When only a text description of a
possible answer is available, it is recorded as ^<text>.
Care should be taken to transmit only those results that are considered
normal for that test. A drug screen may have possible results of "negative"
and "positive." However, only a result of "negative" is considered to be
normal. When an observation has more than one "normal" result, multiple values
in this field should be separated with a repeat delimiter.
Definition: a list of the text answers that are abnormal for the test.
Definition: a list of coded results that are critically abnormal for this
observation.
Definition: the allowed data type for a single categorical observation
(code A or C in OM1-19-nature of observation).
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
ITEM# |
ELEMENT NAME |
1 |
3 |
ST |
|
|
00585 |
Segment
Type ID |
7.B.6.1.0 OM4 field definitions
Definition: this segment applies to observations/batteries that require a
specimen for their performance. When an observation or battery requires
multiple specimens for their performance (e.g., creatinine clearance requires a
24-hour urine specimen and a serum specimen), multiple segments may be
included, one for each specimen type.
Definition: the same value as the sequence number of the associated OM1
segment.
Definition: for some diagnostic studies -- especially in microbiology --
the initial specimen (e.g., blood) is processed to produce results (e.g., the
identity of the bacteria grown out of the culture). The process also produces
new "specimens" (e.g., pure culture of staphylococcus, and E. Coli), and these
are studied by a second order process (bacterial sensitivities). This field
contains codes that identify the parents (e.g., blood culture) and children
(e.g., penicillin MIC) in such cases. The codes are the following:
Value |
Description |
P |
Parent
Observation |
Definition: the physical appearance, including color of tube tops, shape, and
material composition (e.g., red-top glass tube). Note that the color is not
necessarily a unique identifier of the additive and/or use of the tube. This
is especially true for black and some blue tube tops, as can be seen above.
Color is included here for user convenience.
Definition: the capacity of the container.
Definition: reports the units of measure of the container volume. If the
units are ISO+ units, they should be recorded as single case abbreviations. If
the units are ANS+ or L (local), the units and the source code table must be
recorded, except that in this case, component delimiters should be replaced by
subcomponent delimiters. For example, 1 indicates liters, whereas
pt&&ANS+ indicates pints (ANSI units). The default unit is milliliters
(ml), which should be assumed if no units are reported.
Definition: the specimen should be reported as one of the specimen codes
described in ASTM Table 14 of 1238-91. If multiple kinds of specimen are
associated with this observation (as in the case for a creatinine clearance),
separate them with repeat delimiters.
Definition: codes should be those provided by NCCLS[6]. The following list is not exhaustive; it includes only
examples.
NAME |
NCCLS |
DESCRIPTION |
(1)
Lithium Heparin -- anticoagulant |
LIH
Green |
Dry
powder. 10 to 30 USP units per mL of blood |
Definition: the special processing that should be applied to the container,
e.g., add acidifying tablets before sending.
Definition: record special handling requirements here (e.g., ice specimen,
deliver within 2 hours of obtaining).
Definition: record the normal specimen volume required by the lab. This is
the amount used by the normal methods and provides enough specimens to repeat
the procedure at least once if needed. The default unit is milliliters (ml).
Definition: the amount of specimen needed by the most specimen sparing method
(e.g., using micro techniques). The minimum amount allows for only one
determination. The default unit is milliliters (ml).
Definition: other requirements for specimen delivery and special handling
(e.g., delivery within one hour, iced).
Definition: the allowed priorities for obtaining the specimen. Note that
they may be different from the processing priorities given in
OM1-26-processing priority. When a test is requested, the specimen
priority given in OBR-27-quantity/timing should be one of the priorities
listed here. Multiple priorities are separated by repeat delimiters.
Permitted specimen values are the following:
Value |
Description |
S |
Stat
(do immediately) |
Definition: record the usual time that a specimen for this observation is
retained after the observation is completed, for the purpose of additional
testing. The first component is the duration, and the second component is an
ISO time unit.
This segment contains information about batteries and supersets (a nature code
of F, P or S, as described in OM1-19-nature of test/observation).
|
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
ITEM# |
ELEMENT NAME |
1 |
3 |
ST |
|
00585 |
Segment
Type ID |
7.B.7.1.0 OM5 field definitions
Definition: the string OM5 - identifies a record as an observation battery
(set).
Definition: the same value as the sequence number of the associated OM1
segment.
Definition: lists the codes and names of all tests/observations included
within a single battery (nature code P, as described in OM1-19-nature of
test/observation), a single functional procedure (nature code F), or a
given superset (nature code S). When a segment includes a list of component
elements, the sending system should be sure that the segments defining all of
the components are sent before the segment that reference them. An entry in
this list can itself be a battery.
The individual test/observation IDs should be recorded as type CE, i.e., in
the standard format for coded observation identifiers. Multiple observations
should be separated by repeat delimiters.
If the definition segment defined serum electrolytes, this field might look
like the following:
84132^potassium^AS4~
84295^sodium^AS4~
82435^chloride^AS4~
82374^HCO3^^AS4~
For S (superset) parameters, this field contains the batteries that are
included within the "super" battery. For example, ROUTINES might be defined
as:
402^Electrolytes~352^Urinalysis~432^CBC~520^SMA12
Definition: for tests or procedures that produce a type which uses
observation ID suffixes following the test/observation ID code, this field
lists the possible options. The applicable three-character mnemonics given in
ASTM Table 20 (or others appropriate to the application) are listed, separated
by repeat delimiters. For example, a chest x-ray may use the suffixes IMP,
REC, DEV, or others. Each of the expected suffixes should be listed here.
This segment contains information about quantities that are derived from one
or more other quantities or direct observations by mathematical or logical
means.
|
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
ITEM# |
ELEMENT NAME |
1 |
3 |
ST |
00585 |
Segment
Type ID |
7.B.8.1.0 OM6 field definitions
Definition: the string OM6 - identifies a record as an observation that is
derived or calculated from one or more other observations.
Definition: the same value as the sequence number of the associated OM1
segment.
Definition: in the case of patient variables that are derived from one or
more other patient variables (e.g., creatinine clearance, ideal weight, maximum
daily temperature, average glucose, framingham risk), this field contains the
rules for deriving the value of this variable (i.e., nature code C, as given in
OM1-19-nature of test/observation). These can be described in terms of
humanly understandable formulas or descriptions.
When possible, however, they should be defined in terms of the Arden syntax
for specifying selection and transcendative functions and algebraic operations,
ASTM E1460-92. Derivation rules that are represented in Arden syntax should
begin and end with an Arden slot delimiter (;;). Within this syntax, variables
should be identified by OM1-3-producer's test/observation ID. We
recommend the use of the Arden syntax because it permits the unambiguous
specification of most such derived values and is a published standard for
medical logic modules.
Message
ORU 7-14
Narrative Reports 7-4
OBR 7-16
Observation Reporting 7-1
OBX 7-17
OM1 7-58
OM2 7-68
OM3 7-73
OM4 7-74
OM5 7-77
OM6 7-78
ORU 7-14
Query
results observation 7-15
Reporting Units 7-9
Segments
OBR 7-16
OBX 7-17
OM1 7-58
OM2 7-68
OM3 7-73
OM4 7-74
OM5 7-77
OM6 7-78
Test/Observation Master Segments 7-57
Universal (AS4) Identifiers 7-35
1These
AS4 codes are taken directly from ASTM 1238-91, and are printed/adopted with
their permission.[ ]2 The length of the
observation value field is variable, depending upon value type. See
OBX-2-value type.
[ ]3 The
content Appendix 7.A is taken directly from ASTM 1238 and is printed/adapted
with their permission.
[ ]4 Contact:
Michael Huber, Health Outcomes Institute, 2001 Killebrew Dr., Suite 122,
Bloomington, MN 55425;
(612) 858 9188.
[ ]5 Contact
Georges DeMoor, M.D., State University Hospital Gent, De Pintelaan 185-5K3,
9000 Gent, Belgium.
[ ]6 NCCLS
Document H1-A3: Evacuated tubes for blood specimen collection -- Third Edition,
Volume 11, Number 9, Approved standard. July 1991.