Item | DT | Card | Conf | Description | Label |
---|
hl7:ClinicalDocument
| | | | | IHEXDLAB |
hl7:realmCode
| CS | 1 … 1 | R | This element SHALL be present and is valued from the RealmOfUse [2.16.840.1.113883.1.11.11050] subset, within the VocabularyDomainQualifier value set. In the international context of this profile used as it is without any further extension, the realm code SHALL be <realmCode code="UV"/> (universal). Whenever a national extension has been defined and is used, the realm code SHALL identify this national extension. | IHEXDLAB |
| Example | Example for a French extension <realmCode code="FR"/> |
hl7:typeId
| II | 1 … 1 | M | This element is a technology-neutral explicit reference to the standard CDA R2. It SHALL be present and valued as follows: ClinicalDocument/typeId@root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models); ClinicalDocument.typeId@extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description). | IHEXDLAB |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.1.3 |
@extension
| st | 1 … 1 | F | POCD_HD000040 |
hl7:templateId
| II | 1 … 1 | M | This element is identifying the set of constraints applied to the CDA R2 standard by this IHE specification of a laboratory report. The following templateId SHALL be present and valued as follows to indicate compliance with the XD-LAB specification. | IHEXDLAB |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.3.3 |
hl7:id
| II | 1 … 1 | M | ClinicalDocument/Id SHALL be present. It represents the unique instance identifier of the clinical document. The combination of the root and extension attributes SHALL provide a globally unique identifier, in accordance with CDA R2, without further constraints. | IHEXDLAB |
| Example | Example using the extension attribute <id root="1.3.6.1.4.1.19376.1.3.4" extension="abc2"/> |
| Example | Example without the extension attribute <!-- In this case the OID populated in the root attribute is the unique instance identifier itself (The OID in this example is constructed from the OID dedicated to all examples in IHE LAB TF: 1.3.6.1.4.1.19376.1.3.4)--> <id root="1.3.6.1.4.1.19376.1.3.4.1232669"/> |
hl7:code
| CE | 1 … 1 | M | ClinicalDocument/code SHALL be present. The laboratory report can be either a multi-disciplinary report or a single discipline report. Multi-disciplinary Laboratory Report: The LOINC code identifying the type of document as a (potentially) multidisciplinary laboratory report (presenting results from many specialties) is: <code codeSystem="2.16.840.1.113883.6.1" codeSystemName=”LOINC” code="11502-2" displayName="LABORATORY REPORT.TOTAL"/> Single Discipline Laboratory Report: Use the appropriate LOINC code as listed in Value-Set “Laboratory Specialties”. | IHEXDLAB |
| CONF | |
hl7:title
| ST | 0 … 1 | | The Laboratory Specialty Section <title> MAY be present. It is the local translation of the code@displayName. | IHEXDLAB |
hl7:effectiveTime
| TS | 1 … 1 | R | ClinicalDocument/effectiveTime SHALL be present. It contains the creation date & time of the laboratory report as an electronic document. In case this is a new revision replacing a previous version (identified in parentDocument), this is the date & time of the new revision. | IHEXDLAB |
| Example | <effectiveTime value="20080624131933.0000-0500"/> |
hl7:confidentialityCode
| CE | 1 … 1 | R | ClinicalDocument/confidentialityCode SHALL be present in accordance with the HL7 CDA R2 standard. | IHEXDLAB |
hl7:languageCode
| CS | 1 … 1 | R | ClinicalDocument/languageCode SHALL be present in accordance with the HL7 CDA R2 standard. | IHEXDLAB |
| Example | Example of a report authored in American English <languageCode code="en-US"/> |
| Example | Example of a report authored in French <languageCode code="fr-FR"/> |
hl7:setId
| II | 1 … 1 | M | ClinicalDocument/setId SHALL be present to enable further updates of the clinical document. It is an identifier that is common across all revisions of this laboratory report. | IHEXDLAB |
| Example | <setId root="1.3.6.1.4.1.19376.1.3.4" extension="abc2"/> |
hl7:versionNumber
| INT | 0 … 1 | | ClinicalDocument/versionNumber MAY be present. As requested by the CDA standard, it is an integer value used as versioning. | IHEXDLAB |
Choice | 1 … * | | ClinicalDocument/recordTarget SHALL be present and SHALL conform to the Human Patient, Non-Human Subject or Human Patient with Non-Human Subject templates defined below. There are three varieties of laboratory reports: - Human (patient): The document reports laboratory observations produced on specimens collected exclusively from the patient.
- Non-Human Subject: The document reports laboratory observations produced on specimens collected from a non-human material (e.g., water, milk, etc.) or living subject (e.g., animal).
- Human (patient) paired with Non-Human Subject: The document reports laboratory observations produced on a non-human specimen with a relationship to a human patient (e.g., peanut butter eaten by a patient, a ferret that bit a patient).
These three varieties are represented by three templates applied to recordTarget element: Elements to choose from: |
Included | 0 … * | | from 1.3.6.1.4.1.19376.1.3.3.1.1 Human Patient (DYNAMIC) Human (patient): The document reports laboratory observations produced on specimens collected exclusively from the patient. All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. |
hl7:recordTarget
| | 0 … * | R | | Humarget |
hl7:patientRole
| | 1 … 1 | R | | Humarget |
hl7:id
| II | 1 … * | R | | Humarget |
hl7:addr
| AD | 1 … * | | All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. | Humarget |
hl7:telecom
| TEL | 1 … * | | All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. | Humarget |
hl7:patient
| | 1 … 1 | | | Humarget |
hl7:id
| II | 0 … 1 | | | Humarget |
hl7:name
| PN | 1 … * | | | Humarget |
hl7:administrativeGenderCode
| CE | 1 … 1 | R | | Humarget |
hl7:birthTime
| TS | 1 … 1 | R | | Humarget |
Included | 0 … * | | from 1.3.6.1.4.1.19376.1.3.3.1.2 Non-Human Subject (DYNAMIC) Non-Human Subject: The document reports laboratory observations produced on specimens collected from a non-human material (e.g., water, milk, etc.) or living subject (e.g., animal). |
hl7:recordTarget
| | 0 … * | R | | Nonhrget |
@typeCode
| cs | 0 … 1 | F | RCT |
@contextControlCode
| cs | 0 … 1 | F | OP |
hl7:templateId
| II | 1 … 1 | M | | Nonhrget |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.3.3.1.2 |
hl7:patientRole
| | 1 … 1 | R | | Nonhrget |
@classCode
| cs | 0 … 1 | F | PAT |
hl7:id
| II | 1 … * | R | | Nonhrget |
hl7:patient
| | 1 … 1 | | | Nonhrget |
@classCode
| cs | 0 … 1 | F | PSN |
@determinerCode
| cs | 0 … 1 | F | INSTANCE |
@nullFlavor
| cs | 1 … 1 | F | OTH |
Included | 0 … * | | from 1.3.6.1.4.1.19376.1.3.3.1.3 Human Patient with Non-Human Subject (DYNAMIC) Human (patient) paired with Non-Human Subject: The document reports laboratory observations produced on a non-human specimen with a relationship to a human patient (e.g., peanut butter eaten by a patient, a ferret that bit a patient). |
hl7:recordTarget
| | 0 … * | R | | Humarget |
hl7:templateId
| II | 1 … 1 | M | | Humarget |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.3.3.1.3 |
hl7:patientRole
| | 1 … 1 | R | | Humarget |
hl7:id
| II | 1 … * | R | | Humarget |
hl7:addr
| AD | 1 … * | | | Humarget |
hl7:telecom
| TEL | 1 … * | | | Humarget |
hl7:patient
| | 1 … 1 | | | Humarget |
hl7:id
| II | 0 … 1 | | | Humarget |
hl7:name
| PN | 1 … * | | | Humarget |
hl7:administrativeGenderCode
| CE | 1 … 1 | R | | Humarget |
hl7:birthTime
| TS | 1 … 1 | R | | Humarget |
Included | 1 … * | R | from 1.3.6.1.4.1.19376.1.3.10.2.2 XD-LAB Author (DYNAMIC) At least one ClinicalDocument/author SHALL be present with a time in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. The author/time element carries the date&time the laboratory report was produced. The laboratory report can be authored by a software system or by a person or by both. |
hl7:author
| | 1 … * | R | | IHEHthor |
hl7:time
| TS | 1 … 1 | R | The author/time element carries the date&time the laboratory report was produced. | IHEHthor |
hl7:assignedAuthor
| | 1 … 1 | R | | IHEHthor |
hl7:addr
| AD | 1 … * | R | All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. | IHEHthor |
hl7:telecom
| TEL | 1 … * | R | All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. | IHEHthor |
Choice | 0 … 1 | | Elements to choose from: |
hl7:assignedPerson
| | | | All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. Contains 1.3.6.1.4.1.19376.1.3.10.9.18 PlayingEntity or person with Name (DYNAMIC) | IHEHthor |
hl7:assignedAuthoringDevice
| | | | ClinicalDocument/author SHALL be present in accordance with the HL7 CDA R2 standard Contains 1.3.6.1.4.1.19376.1.3.10.9.19 Laboratory Device (DYNAMIC) | IHEHthor |
hl7:representedOrganization
| | 0 … 1 | | All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. Contains 1.3.6.1.4.1.19376.1.3.10.9.13 Organization with Name, Addr, Telecom (DYNAMIC) | IHEHthor |
Included | 1 … 1 | R | from 1.3.6.1.4.1.19376.1.3.10.2.3 XD-LAB Custodian (DYNAMIC) 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. |
hl7:custodian
| | 1 … 1 | R | | IHEHdian |
hl7:assignedCustodian
| | 1 … 1 | R | | IHEHdian |
hl7:representedCustodianOrganization
| | 1 … 1 | R | | IHEHdian |
hl7:id
| II | 1 … * | M | ClinicalDocument/custodian SHALL be present with an id in accordance with the HL7 CDA R2 standard. | IHEHdian |
hl7:name
| ON | 1 … 1 | R | All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. | IHEHdian |
hl7:telecom
| TEL | 1 … 1 | R | All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. | IHEHdian |
hl7:addr
| AD | 1 … 1 | R | All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. | IHEHdian |
Included | 0 … * | | from 1.3.6.1.4.1.19376.1.3.3.1.4 XD-LAB Information Recipient (DYNAMIC) 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. |
hl7:informationRecipient
| | 0 … * | | | Infoient |
hl7:templateId
| II | 1 … 1 | M | | Infoient |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.3.3.1.4 |
hl7:intendedRecipient
| | 1 … 1 | R | | Infoient |
hl7:id
| II | 0 … * | R | | Infoient |
hl7:addr
| AD | 1 … * | | | Infoient |
hl7:telecom
| TEL | 1 … * | | | Infoient |
hl7:informationRecipient
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.3.10.9.18 PlayingEntity or person with Name (DYNAMIC) | Infoient |
hl7:receivedOrganization
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.3.10.9.13 Organization with Name, Addr, Telecom (DYNAMIC) | Infoient |
Included | 0 … 1 | | from 1.3.6.1.4.1.19376.1.3.10.2.4 XD-LAB LegalAuthenticator (DYNAMIC) 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. |
hl7:legalAuthenticator
| | 0 … 1 | | | IHEHator |
hl7:time
| TS | 1 … 1 | R | The sub-element time carries the date&time this legal authentication took place. | IHEHator |
hl7:signatureCode
| CS | 1 … 1 | R | The sub-element signatureCode carries the “signed” (S) status | IHEHator |
@code
| CONF | 0 … 1 | F | S |
hl7:assignedEntity
| | 1 … 1 | R | All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. | IHEHator |
hl7:addr
| AD | 1 … * | R | Constrained by this specification to require the presence of name, addr and telecom. | IHEHator |
hl7:telecom
| TEL | 1 … * | R | Constrained by this specification to require the presence of name, addr and telecom. | IHEHator |
hl7:assignedPerson
| | 0 … 1 | | All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. Contains 1.3.6.1.4.1.19376.1.3.10.9.18 PlayingEntity or person with Name (DYNAMIC) | IHEHator |
hl7:representedOrganization
| | 0 … 1 | | All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. Contains 1.3.6.1.4.1.19376.1.3.10.9.13 Organization with Name, Addr, Telecom (DYNAMIC) | IHEHator |
hl7:authenticator
| | 0 … * | | The ClinicalDocument/authenticator element MAY be present. When present it represents the clinical expert who performed the clinical validation (see the entries “validator” and “clinical expert” in the glossary in LAB TF-1:1.11) of the report or of a subset of its results, also called the validator. This element 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. There MAY be more than one validator of the report. All the validators SHALL appear in the report header as authenticator elements AND, in the case of multiple validators, each individual validator SHALL be associated with the particular sections of the report he or she validated. In this case, the validator of a section SHALL also appear in the entry this section is derived from. This module is consistent with the CDA standard regarding participant and requires in addition the name, addr and telecom for all participants. Contains 1.3.6.1.4.1.19376.1.3.3.1.5 Laboratory Results Validator (DYNAMIC) | IHEXDLAB |
Included | 0 … * | | from 1.3.6.1.4.1.19376.1.3.3.1.6 Ordering Provider (DYNAMIC) 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".
|
hl7:participant
| | 0 … * | | Referral Ordering Physician | Ordeider |
@typeCode
| cs | 1 … 1 | F | REF |
hl7:templateId
| II | 1 … 1 | | | Ordeider |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.3.3.1.6 |
hl7:time
| IVL_TS | 1 … 1 | R | This element represents the date and time the order was placed. Time MAY be present. | Ordeider |
hl7:associatedEntity
| | 1 … 1 | | | Ordeider |
hl7:addr
| AD | 1 … * | R | The address of this person (referral ordering physician) SHALL be present. | Ordeider |
hl7:telecom
| TEL | 1 … * | R | The telecom of this person (referral ordering physician) SHALL be present. | Ordeider |
| Schematron assert | role | error | |
| test | not(hl7:assignedPerson) or hl7:assignedPerson/hl7:name | |
| Message | The <name> sub-element SHALL be present when <assignedPerson> present. | |
hl7:associatedPerson
| | 0 … 1 | R | | Ordeider |
hl7:scopingOrganization
| | 0 … 1 | | | Ordeider |
Included | 0 … * | | from 1.3.6.1.4.1.19376.1.3.10.9.14 XD-LAB InFulfillmentOf Order (DYNAMIC) The inFulfillmentOf/order element MAY be present. It represents the Placer Order or the Placer Group that was fulfilled, the id of which is carried by inFulfillmentOf/order/id. |
hl7:inFulfillmentOf
| | 0 … * | | | IHEIerId |
hl7:order
| | 1 … 1 | R | | IHEIerId |
hl7:id
| II | 1 … * | R | It represents the Placer Order or the Placer Group that was fulfilled, the id of which is carried by inFulfillmentOf/order/id. | IHEIerId |
Included | 0 … * | | from 1.3.6.1.4.1.19376.1.3.10.9.15 XD-LAB DocumentationOf (DYNAMIC) ClinicalDocument/documentationOf(s) MAY be present. |
hl7:documentationOf
| | 0 … * | | | IHEDrmer |
hl7:serviceEvent
| | 1 … 1 | R | | IHEDrmer |
hl7:effectiveTime
| IVL_TS | 0 … 1 | | Use of sub element documentationOf/serviceEvent/effectiveTime to document the time boundaries of events in the document is appropriate. | IHEDrmer |
lab:statusCode
| CS | 0 … 1 | | This Laboratory Report Content Module can express both final and non-final reports. To distinguish between the two, the statusCode element has been added to the documentationOf/serviceEvent element. A non-final report is a report documenting a serviceEvent, which is in the status "active". This sub-element serviceEvent/statusCode is optional. When it is not present the serviceEvent is assumed to be in the status "completed". | IHEDrmer |
| CONF | |
hl7:performer
| | 0 … * | | Laboratory Performer template in the CDA header Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC) | IHEDrmer |
Included | 0 … * | | from 1.3.6.1.4.1.19376.1.3.10.9.16 XD-LAB RelatedDocument (DYNAMIC) 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. |
hl7:relatedDocument
| | 0 … * | | | IHERment |
@typeCode
| cs | 1 … 1 | F | RPLC |
| relatedDocument@typeCode attribute SHALL be valued "RPLC". |
hl7:parentDocument
| | 1 … 1 | R | | IHERment |
hl7:id
| II | 1 … 1 | R | SHALL be equal to ClinicalDocument/ id of the replaced document. | IHERment |
hl7:setId
| II | 1 … 1 | R | SHALL have the same value in the new report as in the replaced report. | IHERment |
hl7:versionNumber
| INT | 1 … 1 | | SHALL have the same value as in the replaced report (when provided there) | IHERment |
Included | 0 … 1 | | from 1.3.6.1.4.1.19376.1.3.10.9.20 XD-LAB ComponentOf (DYNAMIC) 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. |
hl7:componentOf
| | 0 … 1 | | | XDLAntOf |
hl7:encompassingEncounter
| | 1 … 1 | R | | XDLAntOf |
hl7:id
| II | 1 … * | M | | XDLAntOf |
hl7:effectiveTime
| IVL_TS | 1 … 1 | M | | XDLAntOf |
hl7:encounterParticipant
| | 0 … * | | | XDLAntOf |
@typeCode
| cs | 1 … 1 | R | |
hl7:time
| IVL_TS | 1 … 1 | R | | XDLAntOf |
hl7:assignedEntity
| | 1 … 1 | R | | XDLAntOf |
hl7:addr
| AD | 1 … * | R | | XDLAntOf |
hl7:telecom
| TEL | 1 … * | R | | XDLAntOf |
hl7:assignedPerson
| | 0 … 1 | R | | XDLAntOf |
hl7:representedOrganization
| | 0 … 1 | R | | XDLAntOf |
| Schematron assert | role | error | |
| test | not(hl7:assignedPerson) or hl7:assignedPerson/hl7:name | |
| Message | the <name> sub-element of <assignedPerson> SHALL be present. | |
hl7:component
| | 1 … 1 | R | | IHEXDLAB |
hl7:structuredBody
| | 1 … 1 | R | | IHEXDLAB |
hl7:component
| | 1 … * | R | Content Modules for CDA Sections (Level 2) A laboratory report SHALL have a structuredBody. This body is organized as a tree of up to two levels of sections, delivering the human-readable content of the report: Top level sections represent laboratory specialties. A top level section SHALL contain either one text block carrying all the text results produced for this specialty along with a single Laboratory Data Processing Entry or a set of Laboratory Report Item Sections. In the first case the specialty section happens to also be a leaf section. In the latter case, each (second level) leaf section contained in the (top level) specialty section represents a Report Item: i.e., a battery, a specimen study (especially in microbiology), or an individual test. In addition, any leaf section SHALL contain a single Laboratory Data Processing Entry containing the observations of that section in a machine-readable format. Contains 1.3.6.1.4.1.19376.1.3.3.2.1 Laboratory Specialty Section (DYNAMIC) | IHEXDLAB |
| Schematron assert | role | error | |
| test | //hl7:templateId[@root='1.3.6.1.4.1.19376.1.3.1.6'] | |
| Message | Lab report SHALL contain Laboratory Observation | |