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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. In keeping with the mathematical conventions about set, a battery can be a single observation. 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. A test involving waveform recording (such as an EKG) can be represented as a battery comprised of results of many categories, including digital waveform data, labels and annotations to the data, measurements, and the impression
Narrative reports from services such as Radiology usually consist of a number of subcomponents (e.g., a chest X-ray 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.
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). More than one coded anatomic location may be included within a single OBX segment only when such additional codes are used to construct an identity for a single site. In this case only, the OBX-5-observation value field may repeat, with each instance or repetition specifying one of the related locations. Each OBX segment with an ANT suffix could be followed by one or more OBX segments with an IMP or other suffix to transmit the diagnostic impression(s) associated with the anatomic site. These impressions or recommendations would be associated with a single anatomic site via a common observation ID.
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.
To allow the sending system to correlate every result with its associated order, the receiving system will return the placer number in the ORC segment of the OML^O21 message. If desired, this message may also contain information returned from the Observation Recipient, such as the name of the patient corresponding to the order and result placed.
ORC-2-placer order number is the same as OBR-2-placer order number. If the placer order number is not present in the ORC, it must be present in the associated OBR and vice versa. If both fields, ORC-2-placer order number and OBR-2-placer order number, are valued, they must contain the same value. When results are transmitted in an ORU message, an ORC is not required, and the identifying placer order number must be present in the OBR segments.
ORC-3-filler order number is the same as OBR-3-filler order number. If the filler order number is not present in the ORC, it must be present in the associated OBR. (This rule is the same for other identical fields in the ORC and OBR and promotes upward and ASTM compatibility.) This is particularly important when results are transmitted in an ORU message. In this case, the ORC is not required and the identifying filler order number must be present in the OBR segments.
The filler order number (OBR-3 or ORC-3) also uniquely identifies an order and its associated observations. For example, suppose that an institution collects observations from several ancillary applications into a common database and this common database is queried by yet another application for observations. In this case, the filler order number and placer order number transmitted by the common database application would be that of the original filler and placer, respectively, rather than a new one assigned by the common database application.
Although NM is a valid type, observations which are usually reported as numbers will sometimes 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. However, this usage of the ST type should be discouraged since the SN (structured numeric) data type now accommodates such reporting and, in addition, permits the receiving system to interpret the magnitude.
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). LOINC is an HL7 approved code system for the Observation identifier. It covers observations and measurements, such as laboratory tests, physical findings, radiology studies, and claims attachments and can be obtained from www.regenstrief.org/loinc/loinc.htm. One possible universal identifier is LOINC codes for laboratory and clinical measurements (see HL7 defined Table 0396 and the HL7 www list server) and Appendix X2 of ASTM E1467 for neurophysiology tests.
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.
The use of the sub ID to distinguish repeating OBXs for the same observation ID is really a special case of using the sub ID to group, as can be seen if we picture the OBX segments in Figure 7-2 as part of a table where the rows correspond to a particular species of observation and the cells correspond to the sub ID numbers that would be associated with each corresponding OBX.
If the observation includes a number of OBXs with the same value for the observation ID OBX-3, then one must use different values for the sub-ID. This is in fact the case of the repeats depicted in Figure 7-4, but without any need to group sets of OBXs. Three such OBXs could be distinguished by using sub-IDs 1, 2 etc. alternatively, sub-IDs 1.1, 1.2, 1.3 could be used, as shown in Figure 7-4. Figure 7-5 shows and example of an electrocardiograph chest radiograph report with three diagnostic impressions, using 1,2,3 in the sub-ID field to distinguish the three separate results.
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.