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pending Template  Laboratory Report Data Processing Entry

Id 2.16.840.1.113883.2.4.3.11.60.25.10.53
ref
zib2017bbr-
 		Ingangsdatum 2021‑10‑27
Andere versies met dit id:
Status pending Onder revisie vóór de publicatie Versielabel 2017
Naam LaboratoryReportDataProcessingEntry Weergavenaam Laboratory Report Data Processing Entry
Omschrijving
Een Laboratory Report Data Processing Entry MOET aanwezig zijn in iedere onderste sectie van het rapport. Het entry element MOET aanwezig zijn met een templateId/@root attribuut "1.3.6.1.4.1.19376.1.3.1". De entry bevat exact één act element. De act wordt hierna de Specimen Act genoemd. Alle andere CDA level 3 content modules zijn genest in deze ene act. De Specimen Act MOET tenminste één Laboratory Observation bevatten. Als alle observaties van de entry zijn gedaan op hetzelfde specimen, dan MOET dit specimen gekopeld zijn aan de top Specimen Act als een specimen sub-element.
Iedere sectie van het laboratoriumrapport MAG resultaten bevatten die meer vertrouwelijk zijn dan andere resultaten in het rapport (bijv. de sectie over HIV serologie). Dit komt tot uiting via het element confidentialityCode van de Specimen Act.
De Laboratory Report Data Processing Entry MOET zich confirmeren aan de eisen hier en die in de volgende tabellen en secties staan.
Context Sibling nodes van template element met id 2.16.840.1.113883.2.4.3.11.60.25.10.53
Classificatie CDA entry level template
Open/gesloten Open (ook andere dan gedefinieerde elementen zijn toegestaan)
Gebruikt door / Gebruikt
Gebruikt door 2 transacties en 11 templates, Gebruikt 15 templates
Gebruikt door als Naam Versie
bgz2017-transaction-34 Transactie final Aanmaken of bijwerken (2017) 2017‑01‑01
bgz2017-transaction-37 Transactie final Beschikbaarstellen BgZ (2017) 2018‑08‑30 09:30:49
2.16.840.1.113883.2.4.3.11.60.25.10.52 Containment draft Laboratory Specialty Section 2022‑12‑20 14:13:14
2.16.840.1.113883.2.4.3.11.60.42.10.3 link draft BgZ2017 StructuredBody SDTC 2022‑09‑23 15:59:52
2.16.840.1.113883.2.4.3.11.60.42.10.2 link draft BgZ2017 component SDTC 2022‑09‑23 16:01:20
2.16.840.1.113883.2.4.3.11.60.42.10.1 link draft CDA Basisgegevensset Zorg 2017 (BgZ) 2022‑09‑23 16:02:02
2.16.840.1.113883.2.4.3.11.60.25.10.52 Containment active Laboratory Specialty Section 2021‑10‑27
2.16.840.1.113883.2.4.3.11.60.42.10.3 link retired BgZ2017 StructuredBody SDTC 2021‑11‑29
2.16.840.1.113883.2.4.3.11.60.42.10.1 link retired CDA Basisgegevensset Zorg 2017 (BgZ) 2021‑11‑29
2.16.840.1.113883.2.4.3.11.60.42.10.2 link retired BgZ2017 component SDTC 2021‑12‑21 16:54:21
2.16.840.1.113883.2.4.3.11.60.42.10.1 link retired CDA Basisgegevensset Zorg 2017 (BgZ) 2022‑05‑04
2.16.840.1.113883.2.4.3.11.60.42.10.3 link retired BgZ2017 StructuredBody SDTC 2021‑10‑27
2.16.840.1.113883.2.4.3.11.60.25.10.54 Containment active Laboratory Report Item Section (2017) 2021‑10‑27
Gebruikt als Naam Versie
1.3.6.1.4.1.19376.1.3.3.1.2.1 Containment active Non-Human Subject (2017) DYNAMISCH
1.3.6.1.4.1.19376.1.3.3.1.3.1 Containment active Human Patient with Non-Human Subject (2017) DYNAMISCH
1.3.6.1.4.1.19376.1.3.3.1.7 Containment active Laboratory Performer (2017) DYNAMISCH
1.3.6.1.4.1.19376.1.3.3.1.5 Containment active Laboratory Results Validator (2017) DYNAMISCH
1.3.6.1.4.1.19376.1.3.1.1 Containment active Notification Organizer (2017) DYNAMISCH
2.16.840.1.113883.2.4.3.11.60.7.10.3 Containment pending Specimen Collection HCIM 2017‑10‑16
1.3.6.1.4.1.19376.1.3.1.3 Containment active Specimen Received (2017) DYNAMISCH
2.16.840.1.113883.2.4.3.11.60.7.10.2 Containment pending Laboratory Battery Organizer (Specimen) 2021‑08‑30 14:46:35
2.16.840.1.113883.2.4.3.11.60.7.10.4 Containment pending Laboratory Isolate Organizer (Specimen) 2021‑08‑30 14:45:51
2.16.840.1.113883.2.4.3.11.60.7.10.31 Containment pending Laboratory Observation NL 2021‑08‑30 14:16:27
1.3.6.1.4.1.19376.1.5.3.1.4.2 Containment active IHE Comment Entry (2014) DYNAMISCH
1.3.6.1.4.1.19376.1.3.1.1.1 Containment active Notifiable Condition (2017) DYNAMISCH
1.3.6.1.4.1.19376.1.3.1.1.2 Containment active Case Identification (2017) DYNAMISCH
1.3.6.1.4.1.19376.1.3.1.1.3 Containment active Outbreak Identification (2017) DYNAMISCH
1.3.6.1.4.1.19376.1.3.10.9.2 Containment active Multimedia Embedded Content (2017) DYNAMISCH
Relatie Specialisatie: template 1.3.6.1.4.1.19376.1.3.1 Laboratory Report Data Processing Entry (2008‑08‑08)
ref
XDLAB-

Specialisatie: template 2.16.840.1.113883.10.12.301 CDA Act (2005‑09‑07)
ref
ad1bbr-
Voorbeeld
Laboratory Report Data Processing Entry within a Specialty section
<entry typeCode="DRIV">
  <templateId root="1.3.6.1.4.1.19376.1.3.1"/>  <act classCode="ACT" moodCode="EVN">
    <!-- Specialty Level Entry : LOINC Specialty Code -->
    <code code="18719-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Chemistry Studies"/>    <statusCode code="completed"/>    <entryRelationship typeCode="COMP">
      <!-- .. -->
    </entryRelationship>    <!-- .. -->
  </act></entry>
Voorbeeld
Laboratory Report Data Processing Entry within a Report Item Section
<entry typeCode="DRIV">
  <templateId root="2.16.840.1.113883.2.4.3.11.60.25.10.53"/>  <templateId root="1.3.6.1.4.1.19376.1.3.1"/>  <act classCode="ACT" moodCode="EVN">
    <!-- Report Item Level Entry : Result Item Code -->
    <code code="12814-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="POTASSIUM">
      <originalText>Serum potassium</originalText>    </code>    <statusCode code="completed"/>    <entryRelationship typeCode="COMP">
      <!-- .. -->
    </entryRelationship>    <!-- .. -->
  </act></entry>
Item DT Card Conf Omschrijving Label
hl7:templateId
 		II 1 … 1 M (Labdotstry)
@root
 		uid 1 … 1 F 2.16.840.1.113883.2.4.3.11.60.25.10.53
hl7:templateId
 		II 1 … 1 M (Labdotstry)
@root
 		uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.1
hl7:act
 		1 … 1 Er moet een Act sub-element zijn. Deze <act> wordt hierna de Specimen Act genoemd. Dit sub-element gebruikt de modules die zich aan de volgende requirements houden. Deze modules moeten, indien aanwezig, staan in <entryRelationship> elementen onder de Specimen Act.
  • Specimen Collection 2.16.840.1.113883.2.4.3.11.60.7.10.3
  • Specimen Received 1.3.6.1.4.1.19376.1.3.1.3
  • Specimen Site 1.3.6.1.4.1.19376.1.3.1.8
  • Notification Organizer
  • Notifiable Condition
  • Case Identifier
  • Outbreak Identifier
  • Laboratory Isolate Organizer
  • Laboratory Battery Organizer
  • Laboratory Observation
  • Mutimedia Embedded Content
  • Annotation Comment
 (Labdotstry)
@classCode
 		cs 1 … 1 F ACT
@moodCode
 		cs 1 … 1 F EVN
hl7:code
 		CD 1 … 1 M en-US
Mandatory. When section is a Specialty Section, code is a LOINC Specialty. When section is a Report Item Section, code is a Report Item code.
(Labdotstry)
hl7:statusCode
 		CS 1 … 1 M en-US Mandatory.
  • ‘completed’ when all expected results are in a final state
  • ‘active’ if not all expected results are present
  • ‘aborted’ if the tests of this section did not reach completion. Some results MAY be there, but not all.
(Labdotstry)
  CONF
@code moet "completed" zijn
of
@code moet "active" zijn
of
@code moet "aborted" zijn
Keuze 0 … 1 Elementen om uit te kiezen:
hl7:subject
 		0 … 1 en-US subject in case of a non-human subject
Bevat 1.3.6.1.4.1.19376.1.3.3.1.2.1 Non-Human Subject (DYNAMISCH) 		(Labdotstry)
@typeCode
 		cs 0 … 1 F SBJ
hl7:subject
 		0 … 1 en-US subject in case of a non-human subject
Bevat 1.3.6.1.4.1.19376.1.3.3.1.3.1 Human Patient with Non-Human Subject (DYNAMISCH) 		(Labdotstry)
@typeCode
 		cs 0 … 1 F SBJ
hl7:performer
 		0 … * en-US performer participation used if different from the performer of the header, to supersede it for this section.
Bevat 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMISCH) 		(Labdotstry)
@typeCode
 		cs 0 … 1 F PRF
hl7:author
 		0 … * en-US author used if different from the author of the header, to supersede it for this section. (Labdotstry)
hl7:participant
 		0 … * en-US Other participants such as validator (AUTHEN) or responsible party (RESP) or device (DEV)
  • AUTHEN: The verifier of the battery organizer. In the case where a laboratory report has multiple verifiers. Each verifier is attached to the subset of batteries/observations he or she verified, by the means of a <participant> element.

Bevat 1.3.6.1.4.1.19376.1.3.3.1.5 Laboratory Results Validator (DYNAMISCH) 		(Labdotstry)
waar [@typeCode='AUTHEN']
hl7:participant
 		0 … * en-US Other participants such as validator (AUTHEN) or responsible party (RESP) or device (DEV)
  • RESP: The person responsible for the provision of the battery. In the case where this battery is subcontracted to an external laboratory, this external laboratory (with its address and telcom) and the actual performer is represented by a <performer> element, whereas the Director of this subcontractor laboratory is carried by the <participant> element being attached to the same level as the <performer> element.
(Labdotstry)
waar [@typeCode='RESP']
@typeCode
 		cs 1 … 1 F RESP
hl7:participant
 		0 … * en-US Other participants such as validator (AUTHEN) or responsible party (RESP) or device (DEV)
  • DEV: A device or equipment, which was used to produce this battery of results (e.g. an analyzer).
(Labdotstry)
waar [@typeCode='DEV']
@typeCode
 		cs 1 … 1 F DEV
hl7:entryRelationship
 		0 … * R Bevat 1.3.6.1.4.1.19376.1.3.1.1 Notification Organizer (DYNAMISCH) (Labdotstry)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Bevat 2.16.840.1.113883.2.4.3.11.60.7.10.3 Specimen Collection HCIM (2017‑10‑16) (Labdotstry)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Bevat 1.3.6.1.4.1.19376.1.3.1.3 Specimen Received (DYNAMISCH) (Labdotstry)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Bevat 2.16.840.1.113883.2.4.3.11.60.7.10.2 Laboratory Battery Organizer (Specimen) (2021‑08‑30 14:46:35) (Labdotstry)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Bevat 2.16.840.1.113883.2.4.3.11.60.7.10.4 Laboratory Isolate Organizer (Specimen) (2021‑08‑30 14:45:51) (Labdotstry)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Bevat 2.16.840.1.113883.2.4.3.11.60.7.10.31 Laboratory Observation NL (2021‑08‑30 14:16:27) (Labdotstry)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Bevat 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (DYNAMISCH) (Labdotstry)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Bevat 1.3.6.1.4.1.19376.1.3.1.1.1 Notifiable Condition (DYNAMISCH) (Labdotstry)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Bevat 1.3.6.1.4.1.19376.1.3.1.1.2 Case Identification (DYNAMISCH) (Labdotstry)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Bevat 1.3.6.1.4.1.19376.1.3.1.1.3 Outbreak Identification (DYNAMISCH) (Labdotstry)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Bevat 1.3.6.1.4.1.19376.1.3.10.9.2 Multimedia Embedded Content (DYNAMISCH) (Labdotstry)
@typeCode
 		cs 1 … 1 F COMP
  Schematron assert role red error  
  test hl7:entryRelationship  
  Melding A Laboratory Result Content SHALL be present.