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draft Template  Laboratory Report Data Processing Entry

Id 2.16.840.1.113883.2.4.3.11.60.25.10.53
ref
zib2017bbr-
 		Ingangsdatum 2018‑06‑05 14:42:09
Status draft Ontwerp 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 MOET exact een act element bevatten. 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 resultasten 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 0 transacties en 3 templates, Gebruikt 15 templates
Gebruikt door als Naam Versie
2.16.840.1.113883.2.4.3.11.60.25.10.52 Containment draft Laboratory Specialty Section (2017) 2018‑06‑05 14:38:48
2.16.840.1.113883.2.4.3.11.60.25.10.51 link draft Lab2Zorg - Sharing Laboratory Reports (XD-LAB) (2017) 2018‑06‑05 14:37:04
2.16.840.1.113883.2.4.3.11.60.25.10.54 Containment draft Laboratory Report Item Section (2017) 2018‑06‑05 14:44:20
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) 2017‑10‑16
2.16.840.1.113883.2.4.3.11.60.7.10.4 Containment pending Laboratory Isolate Organizer (Specimen) 2017‑10‑16
2.16.840.1.113883.2.4.3.11.60.7.10.31 Containment pending Laboratory Observation NL 2017‑12‑05
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)
treeblank treeblank waar [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.3.1.2.1']]
@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)
treeblank treeblank waar [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.3.1.3.1']]
@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)
treeblank waar [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.3.1.7']]
@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)
treeblank 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)
treeblank 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)
treeblank 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)
treeblank waar [hl7:organizer [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.1.1']]]
@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)
treeblank waar [hl7:procedure [hl7:templateId [@root = '2.16.840.1.113883.2.4.3.11.60.7.10.3'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.1.2']]]
@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)
treeblank waar [hl7:act [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.1.3']]]
@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) (2017‑10‑16) (Labdotstry)
treeblank waar [hl7:organizer [hl7:templateId [@root = '2.16.840.1.113883.2.4.3.11.60.7.10.2'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.1.4']]]
@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) (2017‑10‑16) (Labdotstry)
treeblank waar [hl7:organizer [hl7:templateId [@root = '2.16.840.1.113883.2.4.3.11.60.7.10.4'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.1.5']]]
@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 (2017‑12‑05) (Labdotstry)
treeblank waar [hl7:observation [hl7:templateId [@root = '2.16.840.1.113883.2.4.3.11.60.7.10.31'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.1.6']]]
@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)
treeblank waar [hl7:act [hl7:templateId [@root = '2.16.840.1.113883.10.20.1.40'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.4.2']]]
@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)
treeblank waar [hl7:observation [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.1.1.1']]]
@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)
treeblank waar [hl7:observation [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.1.1.2']]]
@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)
treeblank waar [hl7:observation [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.1.1.3']]]
@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)
treeblank waar [@typeCode = 'COMP'] [hl7:observationMedia [@classCode = 'OBS'] [@moodCode = 'EVN']]
@typeCode
 cs 1 … 1 F COMP
  Schematron assert role red error  
  test hl7:entryRelationship  
  Melding A Laboratory Result Content SHALL be present.