Template  Lab2Zorg - Sharing Laboratory Reports (XD-LAB)

ClinicalDocument/custodian SHALL be present with an id in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. It represents the organization that is in charge of maintaining the laboratory report.

ClinicalDocument/informationRecipient MAY be present. When present, it SHALL be in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name (on the informationRecipient and/or receivedOrganization), addr and telecom. Additionally, it SHALL have the following:

• <templateId root="1.3.6.1.4.1.19376.1.3.3.1.4"/> - The templateId element identifies this participant as an intended recipient. The templateId SHALL have root="1.3.6.1.4.1.19376.1.3.3.1.4".

The informationRecipient/intendedRecipient element can be multiple. It introduces an intended recipient of the laboratory report, other than the Ordering Provider (described as a referrer participant). These elements carry the list of the originally intended recipients of the laboratory report, i.e., those who were known at the time the report was created and published for sharing.

The ClinicalDocument/legalAuthenticator MAY be present. When present, it SHALL be in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. This element carries the person who has legally authenticated the report, and the organization represented by this person. The sub-element time carries the date&time this legal authentication took place. The sub-element signatureCode carries the “signed” (S) status

If this entity happens also to be one of the validators of the laboratory results in the report, it SHALL also be documented as a validator.

ClinicalDocument/participant(s) MAY be present. When present, this element SHALL be in accordance with the HL7 CDA R2 standard with a time element and further constrained by this specification to require the presence of name, addr and telecom. In particular, when the ordering provider of the order (or group of orders) fulfilled by this laboratory report is present in the CDA, it SHALL be documented as a participant with the attribute typeCode valued “REF” (referrer). Additionally, the ordering provider SHALL have the following:

• <templateId root="1.3.6.1.4.1.19376.1.3.3.1.6"/> - The templateId element identifies this participant as an ordering physician. The templateId SHALL have root="1.3.6.1.4.1.19376.1.3.3.1.6".

ClinicalDocument/documentationOf(s) MAY be present.

This element SHALL be present in case of an update replacement of a previous report. In this case relatedDocument@typeCode attribute SHALL be valued "RPLC", the new report replacing the parent one.

The ClinicalDocument/componentOf/encompassingEncounter element MAY be present. It describes the encounter during which the reported lab observations were ordered. When present the encounter SHALL:

• be identified with an id element: encompassingEncounter/id
• The encounter SHALL have an effective time that represents the time interval (possibly still running, e.g., an inpatient current stay) of the encounter or a point in time at which the encounter took place (e.g., an outpatient consultation): encompassingEncounter/ effectiveTime

The encounter MAY provide any number of encounter participants (encompassingEncounter/encounterParticipant/assignedEntity). When present, encounter participants SHALL be in accordance with the HL7 CDA R2 standard with a time and further constrained by this specification to require the presence of name, addr and telecom. Additionally, the encounter participant SHALL have a typeCode with one the values selected from the x_EncounterParticipant domain: The encounter MAY precise the patient location during this encounter. This is the healthcare facility in which the patient was located when the reported lab test observations were ordered: encompassingEncounter/location/healthCareFacility. This healthcare facility can be represented as a physical place (e.g., room, floor, building, office) or as an organization (e.g., service, department, team) or both: healthCareFacility/location, healthCareFacility/serviceProviderOrganization.