Narrative reports from services such as Radiology usually consist of a number of subcomponents (e.g., a chest xray 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.
The current standard treats each component of a narrative report as a separate "test" or observation. Just as a CHEM12 is transmitted as an order segment (OBR) plus 12 OBX segments, a chest xray would be transmitted as an order (OBR) segment plus three OBX segments, one for the description, one for the impression, and one for the recommendations. Similarly, an EKG report would be transmitted as an order segment (OBR), two OBX segments for the impression and recommendation, and additional OBX segments for each EKG measurement, e.g. the PR interval, QR interval, QRS axis, and so on.
We have defined code suffixes for constructing observation IDs for the common components of narrative reports (see Figure 7-1). The observation identifier for each such component is obtained by concatenating the observation battery ID (the ID in OBR-4-universal service ID of the preceding OBR from any coding system) with the appropriate suffix. The observation ID for a chest X-ray impression, for example, would be the chest X-ray observation ID (if CPT4, it would be 71020), a subcomponent delimiter, and the suffix, IMP, i.e., 71020&IMP.
This same combining rule applies to other coding systems including local and universal procedural codes (see Chapter 4). For example, if a local code for EKG was E793, and the locally agreed upon designation for that local code was EKG, the impression would be identified as E793&IMP^^99EKG.
Note: The "99EKG" in the 3rd component is included to indicate a local code. The EKG's description, in this case, would be E793&GDT^^99EKG. |
Although it is strongly discouraged, the sender and receiver may agree to allow the omission of the observation ID component of a result segment when it is the same as the observation ID of the preceding OBR. In this case, only the ampersand and the suffix would have to be sent, e.g., &IMP or &REC, in OBX-3-observation identifier of a result segment. The full code would be assumed as the test identifier (recorded in the order segment) plus the category identifier recorded in the observation segment.
Figure 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 Description Of The Study |
GDT |
TX or FT |
Microscopic Or Secondary Description |
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 |