2.3.4.1 Laboratory Specialty Section

Every Laboratory Report SHALL contain at least one Laboratory Specialty Section. Each top section represents a specialty. A laboratory report MAY be composed of test results from a single specialty (e.g., a microbiology report, a virology report), or from any number of specialties (a report from a multidisciplinary laboratory). The structure of the report allows both kinds of reports.

The Laboratory Specialty Sections use the LOINC codes defined as report subject identifier codes. A laboratory report SHALL contain one or more of these sections, in any order. Laboratory Specialty Sections SHALL NOT be nested.

The semantic content of each specialty section is not constant between countries. The relationship between Report Items and Specialties varies from country to country, and MAY even vary in the same country, from a healthcare organization to another. A Report Item can be a battery (or test panel), an individual test, or the complete study of a specimen (particularly in the MICROBIOLOGY STUDIES specialty). Realm extensions of this profile MAY further constrain these definitions.

A Laboratory Specialty Section SHALL contain EITHER a list of Laboratory Report Item Section(s) OR a single text and entry element to represent the Report Items.

• Choice 1: Laboratory Report Item Section - With this option, this Laboratory Specialty Section SHALL contain NEITHER a top level text NOR entry elements. Each Report Item is contained in a corresponding Laboratory Report Item Section which contains the Lab Report Data Processing Entry. See 2.3.4.2.
• Choice 2: Text and Entry - With this option, the Laboratory Specialty Section text SHALL be present and not blank. This narrative block SHALL present to the human reader, all the observations produced for this Specialty, using the various structures available in the CDA Narrative Block schema (NarrativeBlock.xsd): tables, lists, paragraphs, hyperlinks, footnotes, references to attached or embedded multimedia objects. The narrative block is fully derived from the entry containing the machine-readable result data. Additionally, a single Laboratory Report Data Processing Entry SHALL be present with attribute typeCode="DRIV". This entry contains the machine-readable result data from which the narrative block of this section is derived.

Should a Laboratory Report contain multiple Laboratory Specialty Sections they need not adhere to the same choice of representation, that is, one MAY expect a mixture of choice 1 and choice 2 representations among multiple Laboratory Specialty Sections.