--- tags: USCDI v4 title: Laboratory cat: moderate --- <style>.markdown-body { max-width: 1500px; }</style> Analysis of clinical specimens to obtain information about the health of a patient. ## :new: Laboratory Data Elements <!-- quote --> Draft ![](https://hackmd.io/_uploads/SJBVPoa73.png) Final ![](https://hackmd.io/_uploads/BJVff065h.png) DATA ELEMENT|APPLICABLE VOCABULARY STANDARD(S)<br/>Standards listed are required. If more than one is listed, at least one is required unless otherwise noted. If a cell is empty, an applicable vocabulary standard has not been identified.|US Core V6 Proposal ---|---|--- **Result Unit of Measure**<br/>Unit of measurement to report laboratory test results|The Unified Code of Units for Measure, Revision 2.1|**No Change**: US Core Laboratory Result Observation Profile`Observation.valueQuantity` 0..1 *Must Support* us-core-3: SHALL use UCUM for coded quantity units. **Result Reference Range**<br/>Upper and lower limit of test values expected for a designated population of individuals.<br/>Usage note: reference range values may differ by patient characteristics, laboratory test manufacturer and laboratory test performer.||:new: US Core Laboratory Result Observation Profile`Observation.referenceRange` 0..* *Must Support* **Result Interpretation**<br/>Categorical assessment of a laboratory value, often in relation to a test's reference range.<br/>Examples include but are not limited to high, low, critical, and normal.|Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) U.S. Edition, March 2023 Release<br/><br/>Optional: HL7 Code System ObservationInterpretation|:new: US Core Laboratory Result Observation Profile`Observation.interpretation` 0..* *Must Support* Binding: [ObservationInterpretationCodes](http://hl7.org/fhir/R4/valueset-observation-interpretation.html) (extensible) **Specimen Source Site**<br/>Body location from where a specimen was obtained.<br/>Examples include but are not limited to right internal jugular, left arm, and right eye.|Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) U.S. Edition, September 2022 Release|:new: US Core Specimen Profile`Specimen.collection.bodySite` 0..1 *Additional USCDI Requirement* Binding: [SNOMED CT Body Structures](http://hl7.org/fhir/ValueSet/body-site) (extensible) **Specimen Identifier**<br/>Sequence of characters assigned by a laboratory for an individual specimen.||:new: US Core Specimen Profile`Specimen.identifier` 0..* Must Support **Specimen Condition Acceptability** <br/>Information regarding a specimen, including the container, that does not meet a laboratory’s criteria for acceptability.<br/><br/> Examples include but are not limited to hemolyzed, clotted, container leaking, and missing patient name.<br/><br/> Usage note: This may include information about the contents of the container, the container, and the label.|Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) U.S. Edition, March 2023 Release|:new: US Core Specimen Profile`Specimen.condition` 0..1 *Additional USCDI Requirement* Binding: [hl7VS-specimenCondition](http://terminology.hl7.org/5.0.0/ValueSet-v2-0493.html) (extensible) ### Known issues UCUM codes support :thinking_face: ( historically has been an issue with labs ) USCDI requirements vs Must Support Elements? Unfortunately to confuse everyone and make things more complicated Specimen has both an identifier *and* accessionIdentifier - support one - both - or server's choice with client having to support both - SNOMED CT vs HL7 Codes: - `Observation.interpretation` and `Specimen.condition` bindings listed above are *extensible* in base standard (i.e., you gotta use 'em) - cannot require SNOMED CT except as extensible codes or coding translations. ### Decisions :new: fields in US Core Specimen and US Core Lab Observations (see table) - issue with ONC vs HL7 terminology requirements ### :arrow_right: [Laboratory and Specimen Profiles and Examples](https://healthedata1.github.io/USCDI4-Sandbox/artifacts.html#laboratory) ### IG Updates - [ ] USCDI Mapping Table - [ ] Update US Core Profile - [ ] Implementation Specific Guidance - [ ] New Example(s) - [ ] Update Example(s) ---