Element | Text or code | Code system | Comment | V2 location | |
---|---|---|---|---|---|
Patient Name - do not use | Jack Smith | PID-5, where PID-5.7 = NOUSE | |||
Patient Name to Use | Julie Smith | PID-5, where PID-5.7 = N | |||
Date Name to use and Gender Identity changed | 8/1/2022 (start date) 7/31/2022 (end date) | I picked 8/1/2022, but if the encounter is in August 2021, then that will not work - please provide a date (and optionally time to use here (CS- This works. I miskeyed 2021, but can find replace for 8/1/2022.) | |||
Patient ID | patientID1 | was 19700103 | PID-3.1 | ||
Patient ID Type | MR | PID-3.5 | |||
Patient reference | Patient/example | PID segment | |||
Patient DOB | 1/3/1970 | PID-7 | |||
Patient GI - current | Female | http://snomed.info/sct | GSP, where GSP-4 = 76691-5 and GSP-5 | ||
Patient GI - historic | Male | http://snomed.info/sct | this is in the ADT message, but not in the order or result | GSP, where GSP-4 = 76691-5 and GSP-5 | |
Patient Pronouns - historic | He, Him, His, Himself | http://loinc.org | this is in the ADT message, but not in the order or result | GSP, where GSP-4 = 90778-2 and GSP-5 | |
Patient Pronouns - current | She, Her, Hers, Herself | http://loinc.org | GSP, where GSP-4 = 90778-2 and GSP-5 | ||
Encounter date/time | 2022-08-15T15:31 | Does this mean 1:40 AM??? or am I missing something? That would not be a very realistic visit time - I had picked 08-15-2022 at 3:31 PM (but no timezone offset). CS - this was the date/time in the FHIR example I copied from. I'll update it to your date/time. | |||
Encounter type | outpatient | PV1-2 | |||
Ordered test | 2857-1 | Prostate specific Ag [Mass/Vol] | |||
Order date/time | |||||
Order ID | 911^ClinicOrderSystem | ORC-2 / OBR-2 | |||
Ordering Provider resource ID | by87765446t21h^ClinicOrderSystem | PRT-1 | |||
Ordering Provider Name | Jones, MD | PRT-5, where PRT-4 = OP | |||
SFCU.value | Male | http://snomed.info/sct | GSC-4 | ||
SFCU.comment | The patient has a prostate and is utilizing an estrogenic therapy regimen to suppress testosterone. | GSC-8 | |||
SFCU.supportingInfo | Order | GSC-6 | |||
Sample type | Serum (119364003) | http://snomed.info/sct | this is only in the result message, as the specimen has not been collected at time of order | SPM-4 | |
Testing Lab Assigned Specimen ID | 14MP000051&LabInfoSystem | SPM-2.2 | |||
Sample collection date / time | 08-15-2022 6:01 PM | Depending on encounter date and order date this needs to be later than those during normal lab buisness hours - I had picked 08-15-2022 6:01 PM | SPM-17 (and OBR-7) | ||
Sample received date / time | 08-15-2022 6:01 PM | Depending on encounter date and order date this needs to be later than those during normal lab buisness hours; since the lab is the one that collects the sampel it is the same as the collection date/time - I had picked I had picked 08-15-2022 6:01 PM | SPM-18 | ||
Performing Lab | Clinic Lab One | PRT-8, where PRT-4 = PO | |||
Performing Lab Lab Director | PRT-5, where PRT-4 = POMD | ||||
Performing Lab Director Address | 123 Example Street Example City CA 94133 | PRT-14, where PRT-4 = POMD | |||
Lab Order ID | 000051^LabInfoSystem | ORC-3/OBR-3 | |||
Performed Test | 2857-1 | OBX-3 | |||
Result ID | potentially could use OBX-21, if needed, would need to add to example | ||||
Result value | 3.0 | OBX-5 | |||
Result units | ng/ml | http://unitsofmeasure.org/ | OBX-6 | ||
Reference Range | 0-4.0 ng/ml | OBX-7 | |||
Result interpretation | Normal | https://terminology.hl7.org/3.1.0/CodeSystem-v3-ObservationInterpretation.html | OBX-8 | ||
Result Status | Final | OBX-11 | |||
Result date / time | 08-15-2022 at 5:41 PM | OBX-19 | |||
Result comment | Patients on testosterone suppressing medications, the upper limit of normal for the PSA should be reduced to 1.0 ng/ml. | NTE-3 after OBX | |||
Report (Order) status | Final | OBR-25 | |||
Report date / time | 08-15-2022 at 5:45 PM | OBR-22 | |||