Transaction: Procedure result
General information
STATUS:
Published
OWNER:
eHealth Platform
STANDARD:
KMEHR
VERSION:
1.0
DATE:
2002-10-15
DEFINITION:
The Procedure Result transaction aims to transfer the results of a technical examination, that is typically identified as a service of the RIZIV/INAMI nomenclature.
Results from a clinical investigation should be reported through the transaction Contact report.
Laboratory results are reported through the transaction Laboratory result.
Guidelines
Generalities
This transaction only requires a level 1 of kmehr normalization. However, further levels may be applied (see structure overview).
Transaction elements
id |
id of the transaction according to the ID-KMEHR convention. |
cd |
You must use the value 'result' from CD-TRANSACTION. You can always add your own local codes. |
date |
This is the date of the reporting of the examination(s). By default, this is also the performing date of the examination. If these two dates differ, the performeing date should be defined at the item level. |
time |
This is the time of the reporting of the examination(s). |
author |
This is the person assuming the responsibility of medical content of the request. |
iscomplete |
If this is false, this means that you transfer only part of the information and that the recipient should expect a more complete version later. |
isvalidated |
If this is false, this means that the information has not been validated medically. |
Structure overview
You have the choice between:
- text(s): to transfer your result as free text,
- lnk(s): to encapsulate your result as a multimedia object (Word document for example) or to link the result with the requesting transaction,
- items(s): to further structure your result.
Items
Any item from CD-ITEM can be used but we recommend more particularily the following ones.
| Item type (cd) | Item purpose | Item structure |
| requestnumber | should contain the result number as free text or using KMEHR id | content (text | id) |
| requestdatetime | should contain the request date and time | content (date time) |
| requestor | should identify the prescriber | content hcparty |
| transactionreason | could possibly be used to specify the indication(s) of the examination | content text |
| technical | to specify the result of one technical examination |
content (text | lnk | ...) The lnk element will typically be used to append multiple multimedia attachments like images. If the image is encapsulated within the item, the URL attribute will be left blank. Otherwise, the URL will specify the relative location where to find the image. Very specific elements like the holter or ecg could be developed. Nevertheless we still recommend to use free text and lnk to report technical examinations. |
|
[author] to specify the person that assumes the medical responsability of the result if (s)he differs from the transaction author | ||
|
[beginmoment] to specify the date and time when the service has been performed if it differs from the transaction date (and time) reporting. | ||
|
[lifecyle] to specify the performing status using a value from CD-LIFECYCLE. By default, items contained within a procedure result transaction must be considered as 'reported'. But the following values can be used: 'reported', 'completed' (to inform that the service has been performed but not yet reported), 'planned', 'cancelled'. | ||
|
[site] to specify the body site on which the examination has been done, using a value of CD-SITE |