Collections As Orders And Observations

8.2 Collections as orders and observations

The same LOINC code will be used for ordering a procedure, naming the document produced as the description of the procedure, or naming the structured and coded set of observations from the procedure.

For panels, the same code for CBC would be used as the ordered item in an order record or message, and as the panel identifier in the OBR segment of a result record or message. The same pattern would be followed for laboratory procedures and clinical procedures.

For general collections, the same code would be used as the ordered item in an order record or message, and as the result identifier in a result message. For example, the general collection name could be used in a result message as the identifier of a document type, as a section label, as the universal identifier in an OBR segment, or as the identifier in an OBX segment depending on the circumstances. The same pattern would be followed for radiology procedures and clinical procedures.

We are not taking away the flexibility of having the ordered code be different from the result code. For example, it is often desirable for the order code to be less specific and more abstract than the result code. LOINC would contain codes for something like “Exercise EKG” with the expectation that the result could come back as “AHA Protocol Stress EKG Result”. The point is that, when appropriate, we would use the same LOINC code in the contexts of orders and results. We would NOT make LOINC codes that meant “CBC Order” and “CBC Result”. Rather, we would use the same LOINC code for CBC in both orders and results.

Current practice would also continue where a “pure” procedure is ordered and discrete results would be returned. For example, Urine Microscopic Exam could be ordered and discreet values for cell types, casts, amorphous material, etc. would be returned.