Base Profile for Lab Observations

EHRtoRegistryLaboratoryResultObservationProfile

This profile definition contains the formal specification requirements for representing laboratory observations (derived from the U.S. Core Implementation Guide).

To summarize (for human readers), the following data elements are mandatory (i.e data SHALL be present) or must be supported if the data is present in the sending system:

Each Observation must have:

1. a status
2. a category code of laboratory
3. a LOINC code, if available, which tells you what is being measured
4. a patient

Each Observation must support:

1. a time indicating when the measurement was taken
2. a result value or a reason why the data is absent
   • if the result value is a numeric quantity, a standard UCUM unit

Other implementation guidance:

• Additional codes that translate or map to the Observation code or category codes are allowed. For example:
  • providing both a local code and LOINC code
  • providing a more specific category codes such as chemistry, or system specific codes in addition to the laboratory category code.
• An Observation without a value SHALL include a reason why the data is absent unless there are component observations, or references to other observations that are grouped within it.
• See the definition of Must Support for clarification on its meaning in this context.

Profile Specification

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