橡JAHIS臨床検査データ交換規約

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1 J Japanese A Association of HHealthcare I Information J A H I S Ver. 1.0 S Systems Industry

4 1 1 2 HL HL ORM ORU / MSH 32 NTE PID PV AL ORC OBR OBX 63 7 MERIT 9 69

6 2. HL7 (HL7 ) OSI 7 HL7 ( ) (HL7 ) V1.0 V V V ANSI 1992 HISPP(Healthcare Informatics Standards Planning Panel) 1994 ANSI 1994 V V2.3 V3.0 (HL7 ) HL7 HL7 HL (HL7 ) HL7 OSI 7 ( ) HL7 V2.1 V2.2 V2.3 HL7 ID ( ) ( ( ) ( ) ( ) ASTM E1238 HL7 ANSI HISPP ( HISB) NCPDP( ), ACR/NEMA( DICOM), IEEE MEDIX( ), ASTM( ), ASC X12( ) CEN-TC251(European Committee for Standardization Technical Committee 251) Copyright 1998 JAHIS V1.0 2

8 3. Trigger Event HL7 Message 1 ADT( ) 3 Segment(record) 1 ( ) ID 3 OBR OBX Field Field components ( ) Message Delimiters Placer(Requestor) ( ) X Filler(Producer) ( ) ( ) ( ) Battery 1 Na+ K+ Cl- HCO 3 - (HL7 ) 1 ( ) Copyright 1998 JAHIS V1.0 4

9 HL7 ( ) ( (MSH) ( ( ) 4.2 (ORM) ORM ( ) ORM General Order Message MSH Message Header [{NTE} ] Notes and Comments (for Header) PID Patient Identification [{NTE} ] Notes and Comments (for Patient ID) [ PV1 Patient Visit [ PV2 ] ] Patient Visit 2 [ { AL1 } ] Allergy { ORC Common Order OBR Observation Request [{ NTE } ] Notes and Comments (for OBR) [ { OBX Observation/Result [{ NTE } ] Notes and Comments (for Results) } ] } [ ] { } MSH ( ) PID 1 1 MSH Copyright 1998 JAHIS V1.0 5

10 ORC 1 (OBR) 1 ORC OBR OBX ORC 1 ORC OBR OBX ORC OBR OBX OBR OBX OBR OBX GOT,GPT,HBs OBR 100g OBX, 30 (OBR-4/OBX-3) (OBR-15) OBX 4.3 (ORU) ORU - ORU Observational Results MSH Message Header { PID Patient Identification [{ NTE } ] Notes and comments( for PID) [ PV1 ] Patient Visit { [ ORC ] Order common OBR Observations Report ID [{ NTE } ] Notes and comments( for OBR) [ { OBX Observation/Result [{ NTE } ] Notes and comments( for OBX) } ] } } [ ] { } MSH PID 1 1 PID OBR Copyright 1998 JAHIS V1.0 6

11 (OBR-4/OBX-3) OBX 1 ID OBX ORC 4.4 ORM ORU HL7 V2.3 ORM Seagaia LAB V2.3 mn123 5/23 MSH ^~\& Seagaia LAB ORM^O01 mn123 T 2.3 ~JIS X 0208 JP JIS X 0202 Merit-9 NTE P Merit-9 Example Order OPC-001 IDPID001 PID OPC-001 PID001 OTSUKA^TARO^^^^L^A~ ^ ^^^^L^I~ ^ ^^^^L^P M PV1 O ^ ^ ^^^^L^I AL1 1 DA ^ MO /23 9:30 (GOT,GPT,LDH-ISO) (,30,60,120 ) , , OAL ,30,60,120 4 ORC NW OBR A100^ ^JC ^ ^ ^^^^L^I EC ORC NW OBR ^ set^l ^ ^ ^^^^L^I OAL 1 OBX NM 3B ^GOT^JC9 D OBX NM 3B ^GPT^JC9 D OBX NM 3B ^LDH-ISO^JC9 D ORC NW OBR ^OGTT^L ^ ^ ^ ^^^^L^I OAL 4 OBX NM 3D ^ ^JC9 D OBX NM 3D ^ 30M^JC9 D OBX NM 3D ^ 60M^JC9 D OBX NM 3D ^ 120M^JC9 D HL7 V2.3 ORU LAB Seagaia V2.3 mn256 5/25 MSH ^~\& LAB Seagaia ORU^R01 mn256 T 2.3 ~JIS X 0208 JP JIS X 0202 Merit-9 NTE L Merit-9 Example Result OPC-001 IDPID001 PID OPC-001 PID001 OTSUKA^TARO^^^^L^A~ ^ ^^^^L^I~ ^ ^^^^L^P M 5/ /23 10:00 OBR A100^ ^JC ^ ^ ^^^^L^I EC F ^ OBX TX 9A100&IMP^ ^JC9 AA F 1 4 OAL 5/24 GOT 50U 6-28 GPT 5U 3-9 LDH-ISO 10,30,20,40% OAL 80,150,100,60mg/dl OBR ^OAL ^ set^l ^ ^ ^^^^L^I 1000^YEN OAL F ^ 1 OBX NM 3B ^GOT^JC9 50 U 6-28 H N F OAL Copyright 1998 JAHIS V1.0 7

12 OBX NM 3B ^GPT^JC9 5 U 3-9 N F OAL OBX ST 3B ^LDH-ISO^JC9 F OAL OBX NM 3B ^LDH1^JC9 10 % F OAL OBX NM 3B ^LDH2^JC9 30 % F OAL OBX NM 3B ^LDH3^JC9 20 % F OAL OBX NM 3B ^LDH4^JC9 40 % F OAL OBR ^OAL ^OGTT^L ^ ^ ^ ^^^^L^I 2000^YEN OAL F ^ 4 OBX NM 3D ^ ^JC9 80 mg/dl N F OAL OBX NM 3D ^ 30M^JC9 150 mg/dl N F OAL OBX NM 3D ^ 60M^JC9 100 mg/dl N F OAL OBX NM 3D ^ 120M^JC9 60 mg/dl N F OAL 3 ORM message: MSH... PID... ORC NW A226677^PC ^PC N 3^QAM P123^AQITANE^ELLINORE^""^""^""^MD 4EAST<CR> OBR 9A100^EKG REPORT^JC9 P030^SMITH^MARTIN^""^""^""^MD 3^QAM<CR> MSH... PID... ORC NW... // New order. OBR P42^PC 8A ^Creatinine Clearance^JC9... OBX ST ^Body Weight 62 kg<cr> OBX ST ^Height 190 cm<cr> ORC NW... // Next order.... Copyright 1998 JAHIS V1.0 8

16 5.3 Message Delimiters (16 0D) MSH 4 MSH MSH 2-1 Figure 2-1. Delimiter values - <cr> hex 0D ^ 2 ~ 3 \ TX FT 4 & Segment Terminator ASCII (16 0D) Field Separator HL7 ID MSH 4 Component Separator MSH ^ Repetition Separator MSH ~ Subcomponent Separator MSH & Escape Character (TX FT ) TX FT MSH 3 \ ASCII ASCII Copyright 1998 JAHIS V1.0 12

17 5.4 Data types 2-2. HL7 data types( ) Data type Data Type Name Notes/Format Alphanumeric ST String TX Text data FT Formatted text Numerical CQ Composite quantity with units <quantity (NM)> ^ <units (CE)> MO Money <quantity (NM)> ^ <denomination (ID)> NM Numeric SI Sequence ID SN Structured numeric <comparator> ^ <num1 (NM)> ^ <separator/suffix> ^ <num2 (NM)> Identifier ID Coded values for HL7 tables IS Coded value for user-defined tables HD Hierarchic designator <namespace ID (IS)> ^ <universal ID (ST)> ^ <universal ID type (ID)> Used only as part of EI and other data types. EI Entity identifier <entity identifier (ST)> ^ <namespace ID (IS)> ^ <universal ID (ST)> ^ <universal ID type (ID)> RP Reference pointer <pointer (ST) > ^ < application ID (HD)> ^ <type of data (ID)> ^ <subtype (ID)> PL Person location <point of care (IS )> ^ <room (IS )> ^ <bed (IS)> ^ <facility (HD)> ^ < location status (IS )> ^ <person location type (IS)> ^ <building (IS )> ^ <floor (IS )> ^ <location description (ST)> PT Processing type <processing ID (ID)> ^ <processing mode (ID)> Date/Time DT Date YYYY[MM[DD]] TM Time HH[MM[SS[.S[S[S[S]]]]]][+/-ZZZZ] TS Time stamp YYYY[MM[DD[HHMM[SS[.S[S[S[S]]]]]]]][+/-ZZZZ] ^ <degree of precision> Code Values CE Coded element <identifier (ST)> ^ <text (ST)> ^ <name of coding system (ST)> ^ <alternate identifier (ST)> ^ <alternate text (ST)> ^ <name of alternate coding system (ST)> CF Coded element with formatted values <identifier (ID)> ^ <formatted text (FT)> ^ <name of coding system (ST)> ^ <alternate identifier (ID)> ^ <alternate formatted text (FT)> ^ <name of alternate coding system (ST)> CK Composite ID with check digit <ID number (NM)> ^ <check digit (NM)> ^ <code identifying the check digit scheme employed (ID)> ^ < assigning authority (HD)> CX XCN Extended composite ID with check digit Extended composite ID number and name <ID (ST)> ^ <check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ < assigning authority (HD) )> ^ <identifier type code (IS)> ^ < assigning facility (HD) <ID number (ST)> ^ <family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <source table (IS)> ^ <assigning authority (HD)> ^ <name type code (ID)> ^ <identifier check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ <identifier type code (IS)> ^ <assigning facility (HD)> Generic CM Composite No new CM s are allowed after HL7 Version 2.2. Hence there are no new CM s in Version 2.3. Demographics XAD Extended address <street address (ST)> ^ <other designation (ST)> ^ <city (ST)> ^ <state or province (ST)> ^ <zip or postal code (ST)> ^ <country (ID)> ^ < address type (ID)> ^ <other geographic designation (ST)> ^ <county/parish code (IS)> ^ <census tract (IS)> XPN Extended person name <family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <name type code (ID) > XON XTN Extended composite name and ID number for organizations Extended telecommunications number <organization name (ST)> ^ <organization name type code (IS)> ^ <ID number (NM)> ^ <check digit (NM)> ^ <code identifying the check digit scheme employed (ID)> ^ <assigning authority (HD)> ^ <identifier type code (IS)> ^ <assigning facility ID (HD)> [NNN] [(999)] [X99999] [B99999] [C any text] ^ <telecommunication use code (ID)> ^ <telecommunication equipment type (ID)> ^ < address (ST)> ^ <country code (NM)> ^ <area/city code (NM)> ^ <phone number (NM)> ^ <extension (NM)> ^ <any text (ST)> Waveform CD Channel definition For waveform data only, see Chapter 7, Section <channel identifier (*)> ^ <channel number (NM)> & <channel name (ST)>> ^ <electrode names (*) > ^ Copyright 1998 JAHIS V1.0 13

18 <channel sensitivity/units (*) > ^ <calibration parameters (*)> ^ <sampling frequency (NM)> ^ <minimum/maximum data values (*)> MA Multiplexed array For waveform data only, see Chapter 7, Section <sample 1 from channel 1 (NM)> ^ <sample 1 from channel 2 (NM)> ^ <sample 1 from channel 3 (NM)>...~<sample 2 from channel 1 (NM)> ^ <sample 2 from channel 2 (NM)> ^ <sample 2 from channel 3 (NM)>...~ NA Numeric array For waveform data only, see Chapter 7, Section <value1 (NM)> ^ <value2 (NM)> ^ <value3 (NM)> ^ <value4 (NM)> ^... ED Encapsulated data Supports ASCII MIME-encoding of binary data. <source application (HD) > ^ <main type of data (ID)> ^ <data subtype (ID)> ^ <encoding (ID)> ^ <data (ST)> Records PPN Performing person time stamp: <ID number (ST)> ^ <family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <source table (IS)> ^ <assigning authority (HD)> ^ <name type code(id)> ^ <identifier check digit (ST)> ^ <code identifying the check digit scheme employed (ID )> ^ <identifier type code (IS)> ^ <assigning facility (HD)> ^ < date/time action performed (TS)> Time Series: TQ Timing/quantity For timing/quantity specifications for orders, see Chapter 4, Section 4.4. <quantity (CQ)> ^ <interval (*)> ^ <duration (*)> ^ <start date/time (TS)> ^ <end date/time (TS)> ^ <priority (ID)> ^ <condition (ST)> ^ <text (TX)> ^ <conjunction (ID)> ^ <order sequencing (*)> * for subcomponents of these elements please refer to the definition in the text. Data types ( ) ST ( )ASCII (20 7E 16 ) almost any data at all TX leading spaces are allowed. TX ( CR/LF ) FT (ST) FT (65k ) \.sp\(skip one vertical line) CQ < >^< > 1 2 ISO+ ANSI 123.7^kg kilograms is an ISO unit 150^lb&&ANSI+ weight in pounds is a customary US unit defined within ANSI+. MO Components:<quantity (NM)> ^ <denomination (ID)> 1 2 Copyright 1998 JAHIS V1.0 14

19 ISO-4217 MSH ^USD USD ISO 4217 NM ASCII ( ) ( ) ( ) ASCII <12 SI ID NM SN Components:<comparator (ST)> ^ <num1 (NM)> ^ <separator/suffix / (ST)> ^ <num2 (NM)> > < >= <= = <> = <num1> <num2> / - <num1> - <num2> <num1> <= x <= <num2> X num1 num2 / - + /. : >^100 (greater than 100) ^100^-^200 (equal to range of 100 through 200) ^1^:^228 (ratio of 1 to 128, e.g., the results of a serological test) ^2^+ (categorical response, e.g., occult blood positivity) ID ST ID IS ST IS HL7 HD Components:<namespace ID (IS)> ^ <universal ID (ST)> ^ <universal ID type (ID)> HD UID HD HL7 IS HD HD 2 ID(UID) 3 ID (UID ) UID UID UID UID 1 UID( 2 ) 3 ID Value DNS 0301 ID ASCII Copyright 1998 JAHIS V1.0 15

20 Value GUID UUID HCD CEN (DICOM ) HL7 HL7 ISO L M N base64 ASCII base64 UUID DCE ID x400 X400 MHS ID x500 X , ^ISO ^GUID falcon.iupui.edu^dns 40C983F09183B A ^RANDOM LAB1 Local use only: an HD that looks like an IS data type. PathLab^UCF.UC^L A locally defined HD in which the middle component is itself structured. This can be considered the combination of 'PathLab' with the locally defined UID system "L". LAB1^ ^ISO An HD with an ISO "Object Identifier" as a suffix, and a locally defined system name. ^ ^ISO An HD consisting only of an ISO UID. EI Components:<entity identifier (ST)> ^ <namespace ID (IS)> ^ <universal ID (ST)> ^ < universal ID type (ID)> S) 2 4 (HD) 3 EI EI HD HL RP Components:<pointer (ST) > ^ < application ID (HD)> ^ <type of data (ID)> ^ <subtype (ID)> ST ID HD ( ) ID HL Value Image Image data (HL7 v 2.3) Audio Audio data (HL7 v 2.3) Application Other application data, typically uninterpreted binary data (HL7 v 2.3) HL Copyright 1998 JAHIS V1.0 16

21 Value TIFF PICT DICOM FAX JOT BASIC Octet-stream PostScript JPEG GIF HTML RTF Subtype of referenced data TIFF image data PICT format image data Digital Imaging and Communications in Medicine Facsimile data Electronic ink data (Jot 1.0 standard) ISDN PCM audio data Uninterpreted binary data PostScript program Joint Photographic Experts Group Graphics Interchange Format Hypertext Markup Language Rich Text Format PL Components:<point of care (IS)> ^ <room (IS)> ^ <bed (IS)> ^ <facility (HD)> ^ <location status (IS) > ^ <person location type (IS)> ^ <building (IS)> ^ <floor (IS)> ^ <location description (ST)> HL7 < (IS)> ^ (HD)> ^ < (IS)> ^ < (IS)> ^ < (IS)> ^ < (IS)> ^ < (ST)> ^ < (IS)> PT Components:<processing ID (ID)> ^ <processing mode (ID)> HL7 HL7 ID HL ID HL DT YYYYLLDD TM 24 HHMM[SS[.SSSS]][+/-ZZZZ] (SS) ( ) TM MSH second before midnight in a time zone eleven and half hours ahead of Universal Coordinated Time (i.e., east of Greenwich) Eight AM, local time of the sender seconds after Nine thirty-five AM, local time of sender. TS YYYYLLDD[HHMM[SS[.SSSS]]][+/-ZZZZ]^< > Copyright 1998 JAHIS V1.0 17

22 HHMM 0000 (0 0 ) HL7 ISO (E) (Y = L = D = H = M = S = ) : :01:59 on July 4, 1776 in the Eastern Standard Time zone :01:59 on July 4, 1776 in the Eastern Daylight Saving Time zone Midnight of the night extending from July 4 to July 5, 1988 in the local time zone of the sender ^D Same as prior example, but precision extends only to the day. Could be used for a birthdate.( ) HL7 HL : ( )12 11 HL7 CM CM HL7 CE < & & > HL7 HL7 HL7 / CE Components:<identifier (ST)> ^ <text (ST)> ^ <name of coding system (ST)> ^ <alternate identifier (ST)> ^ <alternate text (ST)> ^ <name of alternate coding system (ST)> 54.21^Laparoscopy^I9^42112^^AS4 F-11380^CREATININE^I9^2148-5^CREATININE^LN 6 <text> ( ) X (ST) ICD-9 ICD-10 SNOMED HL7 nnnn HL7nnnn 3 Copyright 1998 JAHIS V1.0 18

23 2 CE ( ) CF Components:<identifier (ID)> ^ <formatted text (FT)> ^ <name of coding system (ST)> ^ <alternate identifier (ID)> ^ <alternate formatted text (FT)> ^ <name of alternate coding system (ST)> ( X ) 2 5 CE OBX CF 71020^CXR^CPMC 79989^ \H\:\N\\.sp\\ti+4\Heart is not enlarged. There is no evidence of pneumonia, effusion, pneumothorax or any masses.\.sp+3\\h\impression:\n\\.sp\\.ti+4\negative chest.^cpmc CK ID Components:<ID number ID (NM)> ^ <check digit (NM)> ^ <code identifying the check digit scheme employed (ID)> ^ < assigning authority (HD)> PID-3- ID( ID) CK 2 3 Null null M10 M11 Mod 10 Mod ^6^M11^ADT01 Mod10 = Mod Mod Mod11 d = w = W (6 ) c = ( 1) m = 1 (d * w) d = 1 w = ( 2) c1 = m mod 11 Copyright 1998 JAHIS V1.0 19

24 ( 3) c1 =0 c1 =1 ( 4) c =(11 c1) mod 10 : if the number is , then the mod 11 check digit = 6 m =(7*2)+(6*3)+(5*4)+(4*5)+(3*6)+(2*7)+(1*2) = = 106 c1 = 106 mod 11 = 7 c = (11-c1) mod 10 = 4 mod 10 = 4 CX ID Components: <ID (ST)> ^ <check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ < assigning authority (HD) )> ^ <identifier type code ID (IS)> ^ < assigning facility (HD) M11 ADT01 MR University Hospital ID CK ST NM CK ST NM 0203 Value Value AM MA AN MC BR MR DI PI DL PN DN PT DS RR EI SS EN UPIN GI VS GN VN MS XX XCN ID Components:<ID numberid (ST)> ^ <family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <source table (IS)> ^ <assigning authority (HD)> ^ <name type code (ID)> ^ <identifier check digit (ST)> ^ <code identifying the check digit scheme employed (ID )> ^ <identifier type code (IS)> ^ <assigning facility (HD)> 1 8 ID 2 7 PN 8 1 ID XPN 0203 : 12372^RIGGINS^JOHN^""^""^""^MD^ADT ^RIGGINS^JOHN^""^""^""^MD Copyright 1998 JAHIS V1.0 20

25 Smith John J III DR PHD ADT01 L 4 M11 MR XAD Components:<street address (ST)> ^ <other designation (ST)> ^ <city (ST)> ^ <state or province (ST)> ^ <zip or postal code ZIP (ST)> ^ <country (ID)> ^ < address type (ID)> ^ <other geographic designation (ST)>^ <county/parish code / (IS)> ^ <census tract (IS)> 1234 Easy St. Ste. 123 San Francisco CA USA B SF Suite HL SMSA XPN Components: <family name (ST)> ^ <given name (ST)> ^ <middle initial or name ( ) (ST)> ^ <suffix (e.g., JR or III) ( JR) (ST)> ^ <prefix (e.g., DR) ( DR) (ST)> ^ <degree (e.g., MD) ( MD) (ST)> ^ <name type code (ID) > ^ <name representation code (ID)> HL Smith^John^J^III^DR^PHD^L ^ ^^^^^D^I~ ^ ^^^^^D^P~ NIHON^Tarou^^^^^D^A Value A L D M C Name type code (ID) Alias Name Legal Name Display Name Maiden Name Adopted Name Name representation code (ID) Value I A P Ideographic (i.e., Kanji) ( ) Alphabetic (i.e., Default or some single-byte) Phonetic (i.e., ASCII, Katakana, Hiragana, etc) (ASCII, ) XON ID Components: <organization name (ST)> ^ <organization name type code (IS)> ^ <ID Number ID (NM)> ^ <check digit (NM)> ^ <code identifying the check digit scheme employed (ID)> ^ <assigning authority (HD)> ^ <identifier type code (IS)> ^ <assigning facility ID ID (HD)> HL7 Health Center L 6 M11 HCFA 0204 Value A L D SL XTN Components:[NNN ] [(999 )] [X99999] [B99999] [C any text] ^ <telecommunication use cod e (ID)> ^ <telecommunication equipment type Copyright 1998 JAHIS V1.0 21

26 (ID)> ^ < address (ST)> ^ <country code (NM)> ^ <area/city code (NM)> ^ <phone number (NM)> ^ <extension (NM)> ^ <any text (ST)> (415) ORN FX Value PRN ORN WPN VHN ASN EMR NET BPN 0201 ( ) 0202 Value PH FX MD CP BP INTERNET NET X.400 X.400 NET CD Components:<channel identifier (<channel number (NM)> & <channel name (ST)>) > ^ <electrode names (CM)> ^ <channel sensitivity/units (CM)> ^ <calibration parameters (CM)> ^ <sampling frequency (NM)> ^ <minimum/maximum data values (CM)> MA Components:<sample 1 from channel 1 (NM)> ^ <sample 1 from channel 2 (NM)> ^ <sample 1 from channel 3 (NM)>...~<sample 2 from channel 1 ( ) NA ( ) NM ED Components:<source application (HD) > ^ <data subtype (ID)> ^ <encoding (ID)> ^ <data (ST)> RP 0191 HL ASCII HL Value A Hex Base ASCII MIME( ) RFC ASCII 3 Base64 ASCII 65 Copyright 1998 JAHIS V1.0 22

27 Value / = MIME RFC1521 Base64 24 (3 ) 6 64 HL MIME base = (1) 24 = 4 (2) 8 2 = 2 (3) 16 1 = MIME base64 Value/Code Value/Code Value/Code Value/Code 0 A 17 R 34 I 51 z 1 B 18 S 35 j C 19 T 36 k D 20 U 37 l E 21 V 38 m F 22 W 39 n G 23 X 40 o H 24 Y 41 p I 25 Z 42 q J 26 a 43 r K 27 b 44 s L 28 c 45 t M 29 d 46 u 63 / 13 N 30 e 47 v 14 O 31 f 48 w (pad) = 15 P 32 g 49 x 16 Q 33 h 50 y ( ) ASCII PPN Components:<ID number (ST)> ^ <family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <source table (IS)> ^ <assigning authority (HD)> ^ <name type code(id)> ^ <identifier check digit (ST)> ^ <code identifying the check digit scheme employed (ID )> ^ <identifier type code (IS)> ^ <assigning facility (HD)> ^ < date/time action performed (TS)> TS XCN TQ / Copyright 1998 JAHIS V1.0 23

28 5.5 QUANTITY/TIMING (TQ) DEFINITION / Components: <quantity (CQ)> ^ <interval (CM)> ^ <duration (ST)> ^ <start date/time (TS)> ^ <end date/time (TS)> ^ <priority (ST)> ^ <condition (ST)> ^ <text (TX)> ^ <conjunction (ST)> ^ <order sequencing (CM)> / (ORC-7,OBR-27) / / Quantity component (CQ) < & > Interval component (CM) Subcomponents: < & > 1 2 Repeat pattern Repeat pattern Q<integer>S every <integer> seconds Q<integer>M every <integer> minutes Q<integer>H every <integer> hours Q<integer>D every <integer> days Q<integer>W every <integer> weeks Q<integer>L every <integer> months (Lunar cycle) Q<integer>J<day#> J jour(day) < > 1 1= 7= Q2J2 2 Q1J6 BID 1 2 ( 9AM-4PM) TID 1 3 ( 9AM-4PM-9PM) QID 1 4 ( 9AM-11AM-4PM-9PM) xid 1 x X 5 ( 5ID= 5 8ID= 8 ) 4 Q< >H QID Q6H QAM QSHIFT 3 8 QOD (Q2D ) QHS QPM C U <spec> ) < > UNIX PRN PRNxxx xxx ( (PRNQ6H)) Once null Explicit time interval subcomponent 1 HHMM,HHMM,HHMM, ( / 4 ) Copyright 1998 JAHIS V1.0 24

29 / hhmm HS xcy x A P I y M D V Ex: / 2...^QID&0230,0830,1430,2030^ ^TID&PC Duration component INDEF( ) S<integer> = <integer> seconds M<integer> = <integer> minutes H<integer> = <integer> hours D<integer> = <integer> days W<integer> = <integer> weeks L<integer> = <integer> months X<integer> = 2 Q2H X T<integer> = < > DOSAGE INDEF = ( )- Start date/time component (TS) ( )-STAT) End date/time component (TS) Priority component (ID) ( R ) S = A = S R = P = C = T = PRN = As Needed T ( ) Format: TS<integer> = TM<integer> = TH<integer> = TD<integer> = TW<integer> = TL<integer> = Copyright 1998 JAHIS V1.0 25

30 Condition component (ST) PRN pain 110 ( ) Text component (TX) ( ) Conjunction component (ID) null 2 3 a) S = Synchronous (ORC 4 4 ORC 4 5 ) S 2 1 Q15 2 b) A = Asynchronous (ORC 4 4 ORC 4 5 ) A 2 1 1/2 c) C = This is an actuation time ( ) ( ORC 4 5 ORC EKG (3) EKG 3 ^1^QAM^X3^D10 Order sequencing component (complex) (IV) ( 1 ) PRN pain ORC 4 / ORC 4 / / 10 7 ( ) / Subcomponent Contains Notes 1 / S ; C, R 2, 3 / : 2 Copyright 1998 JAHIS V1.0 26

31 Subcomponent Contains Notes HL7 4, 5 / : 2 HL7 6 : <one of "SS", "EE", "SE", or "ES"> +/- <time> 1 (S) (E) (S) (E) / ( ). < > : S<integer> <integer> M<integer> <integer> H<integer> <integer> D<integer> <integer> W<integer> <integer> L<integer> <integer> 7 / 8,9 / : 2 : 2 ID(ST) ID (ID)( ) EI 2 HL7 10,11 / : 2 : 2 ID(ST) ID (ID)( ) EI 2 HL7 ORC 4 / OE1000&OrdEnt ORC OE1001^OrdEnt ES + 10M SS - 10M OE1000&OrdEnt( ) 10 OE1001^OrdEnt( ) ( ) Example: *FS+10M / 4 IV 4 : 1 ORC 4 / IV Copyright 1998 JAHIS V1.0 27

32 / 4 ( ) 1 HL7 4 / / ( ) ( ) ( ) ( 10 ) Examples of quantity/timing usage / 3^once 3 1 1^QHS^X ^C^3D 3 1^Q1H^X4^^^^PVCs>10/min PVC EKG 1^Q2J^^ ^^^^ /21/ ^Q3600S^X5^ /5/89 10: ^QAM^X3^^^^^^S~1^QOD^4D^^^^if K+> ( 2 )1 ^^^ ^^T^^Trough specimen for MIC^C ~^^^^^R 12/12/1988 8:00 Copyright 1998 JAHIS V1.0 28

33 5.6 OBX NTE ID OBX OBX ( X ) ( ) HL7 ID ( 7 1 ) ID( OBR OBR 4 ID ID) X ID X ID(CPT ) IMP ( 71020&IMP ) ID OBR OBX 3 &IMP &REC & 7-1. Observation ID suffices Coded Results Suffix Type Diagnostic Impression IMP CE Recommendation REC CE Confirming Procedures CNP CE Procedure Medication MED CE Anatomic Site ANT CE Device/Instrument / DEV CE Serial # Device/Instrument / SER ST Bulk Text Reports Gross Or General Of The Study GDT TX or FT Microscopic Or Secondary 2 MDT TX or FT Technician's Comment TCM TX or FT Addendum Note ADT TX or FT Other Diagnosis Onset Date/Time ITM TS Diagnosis Resolution Date/Time RTM TS Comparison Study CMS CE Comparison Date/Time CMT TS Comparison Results CMR CE Comparison Change CMC CE Predicted Value PRD ST Percent Predicted PPR ST After Drug Observed AFD ST Predicted Value After Drug ADP ST Percent Predicted After Drug APP ST Timing Information TIM TS Channel Definition Data CHN CD Waveform Digital Data WAS NA or MA Waveform Annotation ANO CE ID Diagnostic impressions (IMP) IMP CE OBX 1 Copyright 1998 JAHIS V1.0 29

34 CE 2 ( ) OBX Recommendations (REC) REC CE 6 ( ) REC Confirming procedure (CNP) OBX IMP OBX OBX 3 ID Procedure medication (MED) MED OBX 3 ( ) OBX OBX 3 1 ( ) OBX 5 2 Anatomic site (ANT) 1 ANT(OBX 3 ) OBX Devices (DEV) OBX 3 DEV CE 2 Serial# Device / Instrument / (SER) Gross or general description (GDT) EKG Copyright 1998 JAHIS V1.0 30

35 Secondary or microscopic description 2 (MDT) 2 OBX 3 MDT Technician comment (TCM) OBX 3 TCM Addendum note (ADT) Diagnosis (problem) onset date-time ( ) (ITM) Diagnosis (problem) resolution date-time ( ) (RTM) Comparison study (CMS) ( ID CMS OBX ) OBX ID Comparison date-time (CMT) Comparison results (CMR) ( ) Comparison change (CMC) ( ) Predicted (PRD) AS &PRD Percent of predicted (PPR) ( )/( ) &PPR After drug observed (AFD) ID AFD AS &AFD Predicted value after drug (ADP) ADP &ADP Copyright 1998 JAHIS V1.0 31

36 Percent predicted after drug (APP) APP AS &APP Timing Information (TIM) TIM OBX ID 1 ID WAV TIM Channel Definition Data (CHN) CHN OBX 1 OBX-5 Waveform Digital Data (WAV) WAV OBX ( / (ADC) ) WAV (CHN OBX ) ID CHN WAV WAV ( OBX ) WAV ( ) WAV NA( ) MA( ) NA MA 1 ( ) 2 ( ) Waveform Annotation (ANO) ANO OBX ( ) ANO (CHN OBX ) ID CHN ANO ANO CE Annotations SAS etc Copyright 1998 JAHIS V1.0 32

37 MSH - message header segment MSH 2-8. MSH attributes SEQ LEN DT OPT RP/# ITEM # ELEMENT NAME 1 1 ST R Field Separator 2 4 ST R Encoding Characters HD O Sending Application HD O Sending Facility HD O Receiving Application HD O Receiving Facility 7 26 TS O Date/Time Of Message / 8 40 ST O Security 9 7 CM R Message Type ST R Message Control ID 11 3 PT R Processing ID 12 8 ID R Version ID NM O Sequence Number ST O Continuation Pointer 15 2 ID O Accept Acknowledgment Type 16 2 ID O Application Acknowledgment Type 17 2 ID O Country Code 18 6 ID O Y/ Character Set CE O Principal Language of Message CE O Escape Sequence Optionality R - required O - optional C - conditional on the trigger event or on some other field(s) X - not used with this trigger event B - left in for backward compatibility with previous versions of HL7 Repetition N - no repetition Y - the field may repeat an indefinite or site determined number of times (integer)- the field may repeat up to the number of times specified in the integer MSH MSH-1 Field separator (ST) ID (MSH-2- ) MSH-2 Encoding characters (ST) ^~\& MSH-3 Sending application (HD) MSH-4 Sending facility (HD) MSH-5 Receiving application (HD) MSH-6 Receiving facility (HD) Copyright 1998 JAHIS V1.0 33

38 MSH-7 Date/time of message (TS) MSH-8 Security (ST) MSH-9 Message type (CM) Components: <message type (ID)> ^ <trigger event (ID)> Message type ( ) Value ORM ORU Value O01 R01 W01 Order message Observ result/unsolicited 0003 Event type ( ) ORM - Order message ORU - Unsolicited transmission of an observation ORU - Waveform result, unsolicited transmission of requested information MSH-10 Message control ID ID (ST) MSH-11 Processing ID ID (PT) Components: <processing ID (ID)> ^<processing mode (ID)> Value D P T Value A R I not present Processing ID ID Debugging Production Training Processing mode Archive Restore from archive Initial load Not present (the default, meaning current processing) MSH-12 Version ID ID (ID) ID 2.3 Value 2.3 HL7 Release Version ID MSH-13 Sequence number (NM) MSH-14 Continuation pointer (ST) MSH-15 Accept acknowledgment type (ID) Copyright 1998 JAHIS V1.0 34

39 MSH-16 Application acknowledgment type (ID) Accept/application acknowledgment conditions Value AL NE ER SU Always Never Error/reject conditions only / Successful completion only MSH-15 MSH-16 ( null) MSH-17 Country code (ID) ISO 3166 MSH-18 Character set (ID) Value ASCII Alternate character sets The printable 7-bit ASCII character set. ( ) 8859/1 The printable characters from the ISO 8859/1 Character set 8859/2 The printable characters from the ISO 8859/2 Character set 8859/3 The printable characters from the ISO 8859/3 Character set 8859/4 The printable characters from the ISO 8859/4 Character set 8859/5 The printable characters from the ISO 8859/5 Character set 8859/6 The printable characters from the ISO 8859/6 Character set 8859/7 The printable characters from the ISO 8859/7 Character set 8859/8 The printable characters from the ISO 8859/8 Character set 8859/9 The printable characters from the ISO 8859/9 Character set JAS2020 JIS X 0202 JIS X JIS X JIS X A subset of ISO2020 used for most Kanji transmissions ISO 2022 with escape sequences for Kanji Code for Information Exchange Code for the Japanese Graphic Character set for information interchange Code of the supplementary Japanese Graphic Character set for information interchange : 7-bit ASCII PN XPN Null single-byte character set (ASCII (ISO IR-6)) ( ISO-IR 6, ISO-IR 13, ISO-IR 14, ISO-IR 100, etc.) ( JIS X 0208) ISO-IR 6 (ISO 646) or ISO-IR 14 (JIS X ) G0 ~JIS X JIS ~JIS X MSH-19 Principal language of message (CE) ISO 639 MSH-20 Escape sequence (CE) 211 JIS X0202 ISO 2022 Copyright 1998 JAHIS V1.0 35

40 6.2 NTE - notes and comments segment NTE NTE NTE attributes SEQ LEN DT OPT RP/# ITEM # ELEMENT NAME 1 4 SI O Set ID - NTE ID-NTE 2 8 ID O Source of Comment 3 64k FT O Y Comment NTE NTE-1 Set ID - NTE ID-NTE (SI) : NTE NTE-2 Source of comment (ID) : 0105 Value L P O Ancillary (filler) department is source of comment Orderer (placer) is source of comment Other system is source of comment NTE-3 Comment (FT) : Copyright 1998 JAHIS V1.0 36

41 6.3 PID - patient identification segment PID 3-2. PID attributes PID SEQ LEN DT OPT RP/# ITEM# ELEMENT NAME 1 4 SI Set ID - Patient ID ID 2 16 CK Patient ID (External ID) ID( ID) 3 20 CX R Y Patient ID (Internal ID) ID( ID) 4 12 ST Y Alternate Patient ID - PID ID 5 48*n XPN R Y Patient Name 6 48 XPN Mother's Maiden Name 7 26 TS Date/Time of Birth 8 1 IS Sex 9 48 XPN Y Patient Alias 10 1 IS Race XAD Y Patient Address 12 4 IS County Code XTN Y Phone Number - Home XTN Y Phone Number - Business CE Primary Language 16 1 IS Marital Status 17 3 IS Religion CX Patient Account Number ST SSN Number - Patient SSN CM Driver's Lic Num - Patient CX Mother's Identifier 22 3 IS Ethnic Group ST Birth Place 24 2 ID Multiple Birth Indicator 25 2 NM Birth Order 26 4 IS Y Citizenship CE Veterans Military Status CE Nationality TS Patient Death Date and Time 30 1 ID Patient Death Indicator PID PID-1 Set ID - patient ID ID (SI) ID ID PID PID-2 Patient ID (external ID) ID( ID) (CK) ID ID PID-3 Patient ID (internal ID ID( ID) (CX) ID( ID ) ORM ID PID-4 Alternate patient ID - PID ID (ST) ID ID ID PID-5 Patient name (XPN) : <family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix Copyright 1998 JAHIS V1.0 37

42 (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <name type code (ID) > ^ <name representation code (ID)> Value A L D M C Value I A P Name type Alias Name Legal Name Display Name Maiden Name ( ) Adopted Name 4000 name representation code Ideographic (i.e., Kanji) Alphabetic (i.e., Default or some single-byte) Phonetic (i.e., ASCII, Katakana, Hiragana, etc.) (ASCII, ) MSH-18 ASCII~JIS X PID-5 Yamada^Tarou^^^^L^A~ ^ ^^^^L^I~ ^ ^^^^L^P L PID-6 Mother's maiden name (XPN) M PID-7 Date/Time of birth (TS) nnnu Y L W D Y (YYYYLLDDHHMMSS^nnnu) ^ ^10 10 ^5D 5 PID-8 Sex (IS) Value F M O U PID-9 Patient alias (XPN) Female Male Other Unknown PID-10 Race (IS) PID-11 Patient address (XAD) PID-12 County code (IS) PID-13 Phone number - home (XTN) PID-14 Phone number - business (XTN) PID-15 Primary language (CE) Copyright 1998 JAHIS V1.0 38

43 PID-16 Marital status (IS) Marital status Value A D M S W Separated Divorced Married Single Widowed PID-17 Religion (IS) PID-18 Patient account number (CX) PID-19 SSN number - patient SSN (ST) PID-20 Driver's license number - patient (CM) PID-21 Mother's identifier (CX) ID PID-22 Ethnic group (IS) PID-23 Birth place (ST) PID-24 Multiple birth indicator (ID) Y/N PID-25 Birth order (NM) PID-26 Citizenship (IS) ISO3166 PID-27 Veterans military status (CE) PID-28 Nationality (CE) PID-29 Patient death date and time (TS) PID-30 Patient death indicator (ID) Y/N Copyright 1998 JAHIS V1.0 39

44 6.4 PV1 - patient visit segment PV1 /ADT 3-3. PV1 attributes SEQ LEN DT OPT RP/# ITEM# ELEMENT NAME 1 4 SI O Set ID - Patient Visit ID 2 1 IS R Patient Class 3 12 PL O Assigned Patient Location 4 2 IS O Admission Type 5 20 CX O Preadmit Number 6 12 PL O Prior Patient Location 7 60 XCN O Y Attending Doctor 8 60 XCN O Y Referring Doctor 9 60 XCN O Y Consulting Doctor 10 3 IS O Hospital Service PL O Temporary Location 12 2 IS O Preadmit Test Indicator 13 2 IS O Readmission Indicator 14 3 IS O Admit Source 15 2 IS O Y Ambulatory Status 16 2 IS O VIP Indicator VIP XCN O Y Admitting Doctor 18 2 IS O Patient Type CK O Visit Number CM O Y Financial Class 21 2 IS O Charge Price Indicator 22 2 IS O Courtesy Code 23 2 IS O Credit Rating 24 2 IS O Y Contract Code 25 8 DT O Y Contract Effective Date NM O Y Contract Amount 27 3 NM O Y Contract Period 28 2 IS O Interest Code 29 1 IS O Transfer to Bad Debt Code 30 8 DT O Transfer to Bad Debt Date IS O Bad Debt Agency Code NM O Bad Debt Transfer Amount NM O Bad Debt Recovery Amoun t 34 1 IS O Delete Account Indicator 35 8 DT O Delete Account Date 36 3 IS O Discharge Disposition IS O Discharged to Location 38 2 IS O Diet Type 39 2 IS O Servicing Facility 40 1 IS O Bed Status 41 2 IS O Account Status PL O Pending Location PL O Prior Temporary Location TS O Admit Date/Time / TS O Discharge Date/Time / NM O Current Patient Balance NM O Total Charges NM O Total Adjustments NM O Total Payments CX O Alternate Visit ID ID 51 1 IS O Visit Indicator XCN O Y Other Healthcare Provider PV1 Copyright 1998 JAHIS V1.0 40

45 PV1-1 Set ID - patient visit ID (SI) PV1-2 Patient class (IS) Patient class Value E I O P R B C Emergency Inpatient Outpatient Preadmit Recurring Patient Obstetrics Checkup PV1-3 Assigned patient location (PL) : <point of care (IS )> ^ <room (IS )> ^ <bed (IS )> ^ <facility (HD)> ^ < location status (IS )> ^ <person location type (IS)> ^ <building (IS )> ^ <floor (IS )> ^ <location description (ST)> PL 5 ( ) PV Bed status Value C H O U K I Closed Housekeeping Occupied Unoccupied Contaminated Isolated PV1-4 Admission type (IS) Admission type Value A E L R Accident Emergency Labor and Delivery Routine PV1-5 Pre-admit number (CX) PV1-6 Prior patient location (PL) NULL PV1-7 Attending doctor (XCN) ID PV1-8 Referring doctor (XCN) ID PV1-9 Consulting doctor (XCN) Copyright 1998 JAHIS V1.0 41

46 PV1-10 Hospital service (IS) A01,A02,A14,A15 PV1-11 Temporary location (PL) ( OR). PV1-12 Pre-admit test indicator (IS) PV1-13 Re-admission indicator (IS) R Null PV1-14 Admit source (IS) PV1-15 Ambulatory status (IS) Value A0 A1 A2 A3 A4 A5 A6 A7 A8 A9 B1 B2 B3 B4 B5 B Ambulatory status No functional limitations Ambulates with assistive device Wheelchair/stretcher bound / Comatose; non-responsive Disoriented Vision impaired Hearing impaired Speech impaired Non-English speaking Functional level unknown Oxygen Therapy Special equipment (tubes, IVs, catheters) ( IV ) Amputee Mastectomy Paraplegic Pregnant PV1-16 VIP indicator VIP (IS) VIP PV1-17 Admitting doctor (XCN) ID PV1-18 Patient type (IS) PV1-19 Visit number (CK) PV1-20 Financial class (CM) PV1-21 Charge price indicator (IS) PV1-22 Courtesy code (IS) PV1-23 Credit rating (IS) PV1-24 Contract code (IS) Copyright 1998 JAHIS V1.0 42

47 PV1-25 Contract effective date (DT) PV1-26 Contract amount (NM) PV1-27 Contract period (NM) PV1-28 Interest code (IS) PV1-29 Transfer to bad debt code (IS) PV1-30 Transfer to bad debt date (DT) PV1-31 Bad debt agency code (IS) PV1-32 Bad debt transfer amount (NM) PV1-33 Bad debt recovery amount (NM) PV1-34 Delete account indicator (IS) PV1-35 Delete account date (DT) PV1-36 Discharge disposition (IS) ( ) PV1-37 Discharged to location (IS) PV1-38 Diet type (IS) PV1-39 Servicing facility (IS) PV1-40 Bed status (IS) PL 5 PV1-41 Account status (IS) PV1-42 Pending location (PL) ID 5 ( ) PV1-40 PV1-43 Prior temporary location (PL) PV1-44 Admit date/time (TS) / PV1-45 Discharge date/time (TS) / Copyright 1998 JAHIS V1.0 43

48 PV1-46 Current patient balance (NM) PV1-47 Total charges (NM) PV1-48 Total adjustments (NM) PV1-49 Total payments (NM) PV1-50 Alternate visit ID ID (CX) ID ID PV1-51 Visit indicator (IS) Visit Indicator Value A no value Account Level Visit Level PV1-52 Other healthcare provider (XCN) ( ) Copyright 1998 JAHIS V1.0 44

49 6.5 AL1 - patient allergy information segment AL1 AL AL1 attributes SEQ LEN DT OPT RP/# ITEM# ELEMENT NAME 1 4 SI R Set ID - Allergy ID 2 2 IS Allergy Type 3 60 CE R Allergy Code/Mnemonic/ / 4 2 IS Allergy Severity 5 15 ST Allergy Reaction 6 8 DT Identification Date AL1 AL1-1 Set ID - allergy ID (SI) ID AL1-2 Allergy type (IS) ( ) 127 Value DA FA MA MC Allergy type Drug Allergy Food Allergy Miscellaneous Allergy Miscellaneous Contraindication AL1-3 Allergy code/mnemonic/description / (CE) ( ) AL1-4 Allergy severity (IS) ( ) Allergy severity Value SV MO MI Severe Moderate Mild AL1-5 Allergy reaction (ST) ( ) AL1-6 Identification date (DT) Copyright 1998 JAHIS V1.0 45

50 6.6 ORC - common order segment (ORC) ( ) ORC ORC OK < > < > <CR> ORC (HD ORC-1 ORC-2 ORC-3 ) ORC ORC a) 1 1 ORC-4- (ORCs) ORCs b) ORC ( ) ORC ( OBR RXO) ORC-2 OBR-2 ASTM ORC c) / 1)EKG 3 EKG 3 2)EKG 3 EKG 1 3) 1 EKG ( ) 4) 4-1. ORC attributes ORC SEQ LEN DT OPT RP/# ITEM# ELEMENT NAME 1 2 ID R Order Control 2 22 EI C Placer Order Number 3 22 EI C Filler Order Number 4 22 EI O Placer Group Number 5 2 ID O Order Status 6 1 ID O Response Flag TQ O Quantity/Timing / CM O Parent 9 26 TS O Date/Time of Transaction XCN O Entered By XCN O Verified By XCN O Ordering Provider PL O Enterer's Location XTN O Y/ Call Back Phone Number TS O Order Effective Date/Time CE O Order Control Code Reason CE O Entering Organization CE O Entering Device XCN O Action By Copyright 1998 JAHIS V1.0 46

51 ORC ORC-1 Order control (ID) a) NW ( ) CA ( ) b) OK ( ) CR ( ) c) OC ( ) OD ( ) ( CR) ( CA) 0119 Value 1 Originator 2 Field Note 3 NW New order P I OK Order accepted & OK & OK F I UA Unable to Accept Order F n CA Cancel order request P a OC Order canceled F CR Canceled as requested ( ) F UC Unable to cancel ( ) F b DC Discontinue order request P c OD Order discontinued F DR Discontinued as requested ( ) F UD Unable to discontinue ( ) F HD Hold order request P OH Order held F UH Unable to put on hold ( ) F HR On hold as requested ( ) F RL Release previous hold P OE Order released F OR Released as requested ( ) F UR Unable to release ( ) F RP Order replace request P e,d,h RU Replaced unsolicited ( ) F f,d,h RO Replacement order P,F g,d,h,l RQ Replaced as requested F d,e,g,h UM Unable to replace ( ) F PA Parent order F I CH Child order F,P i XO Change order request P XX Order changed, unsol. ( ) F Copyright 1998 JAHIS V1.0 47

52 Value 1 Originator 2 Field Note 3 UX Unable to change ( ) F XR Changed as requested ( ) F DE Data errors P,F RE Observations to follow P,F j RR Request received P,F k SR Response to send order status request F SS Send order status request P SC Status changed F,P SN Send order number F l NA Number assigned P l CN Combined result F m RF Refill order request F, P o AF Order refill request approval P p DF Order refill request denied P q FU Order refilled, unsolicited F r OF Order refilled as requested F s UF Unable to refill F t ORC a) CA CR (ORC-1- ) b) UC UC ( ) ORC-6- c) DC d) RP, RQ, RU, RO 1 / RP( ) ORC-1- RU( )) RU ORC (RP RU ) ORC (RP RU ) RO( ) ORC-1- ORC RO ORC 2 OBR RU and RO usage (example) Segment Order Control Comment Copyright 1998 JAHIS V1.0 48

53 Segment Order Control Comment ORC RU 1st replaced ORC OBR 1st replaced order's detail segment ORC RU 2nd replaced ORC OBR 2nd replaced order's detail segment ORC RO 1st replacement ORC OBR 1st replacement order's detail segment ORC RO 2nd replacement ORC OBR 2nd replacement order's detail segment ORC RO 3rd replacement ORC OBR 3rd replacement order's detail segment ORC-6- OBR RP 2 RU( )) 2 RQ( ) 4-3. RQ and RO usage (example) Segment Order Control Comment ORC RQ 1st replaced ORC OBR 1st replaced order's detail segment ORC RQ 2nd replaced ORC OBR 2nd replaced order's detail segment ORC RO 1st replacement ORC OBR 1st replacement order's detail segment ORC RO 2nd replacement ORC OBR 2nd replacement order's detail segment ORC RO 3rd replacement ORC OBR 3rd replacement order's detail segment e) RP, RQ 1 1 f) RU ( ) g) RO, RQ RP RU h) RP, RQ, RU, RO RO ORC (RP RU) RU ( ) RU ORC RP ( ) ORU ( ) 1) RO ORC 2) OBR ( ) Copyright 1998 JAHIS V1.0 49

54 3) (OBX) 4) NTE ORU OBR( ) OBX i) PA, CH (PA) (CH) ( ) PA ORC-1-1 ORC CH ORC-1-1 ORC ORC-6- OBR Example of two child orders Segment Order Control Comment ORC PA 1st parent ORC ORC CH 1st child ORC OBR 1st child order ORC CH 2nd child ORC OBR 2nd child order SN/NA 2 SN/NA ORC ORC-8- ( ) ( ) 3 EKG j) RE ( OBR) 1 (OBX) ORU 3 RE 4-5. RE usage (example) Segment Order Control Comment MSH PID ORC NW First new order RXO First order segment ORC NW 2nd new order RXO 2nd order segment [ORC RE Patient-specific observation, optional in V 2.2 OBR] Observation OBR, optional in V 2.2 OBX An observation segment OBX Another observation segment OBX Another observation segment OBX Another observation segment ORC NW 3rd order RXO 3rd order segment HL7 1 OBX Copyright 1998 JAHIS V1.0 50

55 ORC OBR ORC ORU ORU OBR ORC ORU RE ORM (OBX) RE ORU OBR (OBX) k) RR l) SN, NA, NW 3 (ORC-2-3- ) 1) HIS ORC-3-2) ORC- 2-3) ( ) ORC-3-1) SN ORC-3- HIS ( ) HIS SN ORC-1- ORM ORC Null ORC-3- ORC-2- ORM(SN ) 2 i) OK ORC-1- ORR ORM NA ORC-1- ORC ii) NA ORC-l- ORR NA ORC-1- NA ORC-2- (SN ORC ) ID. Code From ORC-2-Placer Order Number ORC-3-Filler Order Number SN filler application placer order number^filler application ID null NA other application placer order number^filler application ID filler order number^filler application ID 2) SN ORC-2- SN ORC-1- ORM ORC null ORC-2- ORC-3- ORM(SN ) 2 i) OK ORC-1- ORR ORM NA ORC-1- ORC Copyright 1998 JAHIS V1.0 51

56 ii) NA ORC-l- ORR NA ORC-2- ORC NA ORC-1- ORC-2- ORC-3- (SN ORC ) Code From ORC-2-Placer Order Number ORC-3-Filler Order Number SN filler application null filler order number^filler application ID NA other application placer order number^placer application ID filler order number^filler application ID 3) NW ( ) RO (RO following an RP). ORC3-2 ID Code From ORC-2-Placer Order Number ORC-3-Filler Order Number NW, RO other application to the filler placer order number^placer application ID filler order number^filler application ID m) CN CN ORC RE ORC OBR 3 ORC MSH... PID... ORC CN... OBR A4461XA^HIS 81641^RAD 73666^Bilateral Feet... ORC CN... OBR A4461XB^HIS 81642^RAD 73642^Bilateral Hand PA... ORC RE... OBR A4461XC^HIS 81643^RAD 73916^Bilateral Knees... OBX CE 73916&IMP Radiologist's Impression... OBX CE 73642&IMP Radiologist's Impression... OBX FT 73642&GDT... n) UA MSA. o) RF RF p) AF AF q) DF DF NCPDF SCRIPT Copyright 1998 JAHIS V1.0 52

57 AA AB AC AD AE AF AG Patient unknown to the provider Patient never under provider care Patient no longer under provider care Patient has requested refill too soon Medication never prescribed for the patient Patient should contact provider first Refill not appropriate FU OF UF r) FU. s) OF t) UF ORC-2 Placer order number ( EI) ( (OBR)) 15 ( ) 2 ID 6 ID 2 3 a) RU RO ORC-1- b) CH( ) ORC-1- c) SN( ) ORC-1- ORC-2- ORC-1- ID 1 ( ) ORM ORR ID (MSH ) ORC-2- OBR-2- ORC OBR ORC-2- OBR-2- ORU ORC OBR ORC OBR ( / ) ORC-3 Filler order number ( EI) ( OBR) ( ( ) ( ) 2 ID 6 Copyright 1998 JAHIS V1.0 53

58 2 ID 1 ( ) ORM ORR ID (MSH ) ORC-3- OBR-2- ORC OBR ( ORC OBR ASTM ) ORU ORC OBR (OBR-3 ORC-3) ( ) ORM CA ORC-1 ORC ORC-4 Placer group number (EI) ORC 2 ID ORC-2-2 ORC-5 Order status (ID) (ID) ORC-1- SR SC Value A CA CM DC ER HD IP Order status Some, but not all, results available Order was canceled Order is completed Order was discontinued Error, order not found Order is on hold In process, unspecified Copyright 1998 JAHIS V1.0 54

59 Value RP SC Order has been replaced In process, scheduled ORC-6 Response flag (ID) ( ) ( ) null D Value E R D F N Response flag Report exceptions only Same as E, also Replacement and Parent-Child E Same as R, also other associated segments R Same as D, plus confirmations explicitly D Only the MSA segment is returned MSA ORC-7 Quantity/timing / (TQ) OBR ORC-7- / 1-XQAM X3 ORC-7- / OBR-27- / ORC-8 Parent (CM) Components: <parent's placer order number (EI)> ^ <parent's filler order number (EI)> Subomponents of parent s placer order number: <entity identifier (ST)> & <application identifier 1(IS)> & <universal identifier (UI)> Subomponents of parent s filler order number: <entity identifier (ST)> & <application identifier 1(IS)> & <universal identifier (UI)> ORC ORC-8- OBR-29- ORC-9 Date/time of transaction (TS) ORC-10- ORC-11- ORC-13- ORC-10 Entered by (XCN) ID ORC-11 Verified by (XCN) ID Copyright 1998 JAHIS V1.0 55

60 ORC-12 Ordering provider (XCN) ORC-12- OBR-16- ORC-13 Enterer's location (PL) ( ) ICU4 4 ICU ORC-14 Call back phone number (XTN) ORC-14- OBR-17- ORC-15 Order effective date/time (TS) ORC-9- ( ) ORC-15- ORC-16- ORC ORC-9- ORC-15- ORC ORC-15- ORC-9- MSH-7- ORC-15- ( ORC ) ORC-7- / ORC-15- ORC ORC-7- / ORC ORC-16 Order control code reason (CE) ( 0119) ( RXO ORO OBR) NTE ORC-1- NW ORC-16- ( ) ORC-17 Entering organization (CE) / ORC-18 Entering device (CE) ( PC) ORC-19 Action by (XCN) CA( ) Copyright 1998 JAHIS V1.0 56

61 6.7 OBR - observation request segment (ASTM ) (OBR) ( EKG) ( ) 1 1 ( X ) ( CBC ) ( ) X( ) OBR 25 (OBR) (OBX) OBX 4 8 OBR ( ) OBR ( ) ( ) OBR 7 / OBR 8 / ( ) 2 (BP X ) 4-8. OBR attributes OBR SEQ LEN DT OPT RP/# ITEM # ELEMENT NAME 1 4 SI C Set ID - Observation Request ID 2 75 EI C Placer Order Number 3 75 EI C Filler Order Number CE R Universal Service ID ID 5 2 ID B Priority 6 26 TS B Requested Date/time 7 26 TS C Observation Date/Time # / 8 26 TS O Observation End Date/Time # / 9 20 CQ O Collection Volume * XCN O Y Collector Identifier * 11 1 ID O Specimen Action Code * CE O Danger Code ( ) ST O Relevant Clinical Info TS C Specimen Received Date/Time * CM O Specimen Source * XCN O Y Ordering Provider Copyright 1998 JAHIS V1.0 57

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