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Template Human Patient 2017‑06‑07

Id1.3.6.1.4.1.19376.1.3.3.1.1
ref
XDLAB-
Effective Date2017‑06‑07
Statusactive ActiveVersion Label2017
NameHumanpatientrecordtargetDisplay NameHuman Patient
Description
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…) 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).

Human Patient

In accordance with the HL7 CDA R2 standard and further constrained by this specification, XD-LAB requires the presence of name, addr and telecom for all entities in the document including the human patient. Additionally, the following SHALL be present.
  • An optional templateId with root="1.3.6.1.4.1.19376.1.3.3.1.1" - The templateId element identifies this recordTarget as a human patient.
  • id - The patientRole/id SHALL be present.
  • administrativeGenderCode - The patientRole/patient/administrativeGenderCode SHALL be present.
  • birthTime - The patientRole/patient/birthTime SHALL be present.
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 4 templates, Uses 0 templates
Used by as NameVersion
2.16.840.1.113883.2.6.60.6.4.2Transactiondraft CDA Document Anatomic Pathology Structured Report 2015 (2.0)2015‑10‑23 10:32:36
1.3.6.1.4.1.19376.1.3.3Includeactive Sharing Laboratory Reports (XD-LAB) Content Module (2017)2016‑07‑05
1.3.6.1.4.1.19376.1.8.1.1.1Includedraft Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
2.16.840.1.113883.2.4.3.11.60.25.10.51Includedraft Lab2Zorg - Sharing Laboratory Reports (XD-LAB) (2017)2018‑06‑05 14:37:04
2.16.840.1.113883.3.1937.99.61.67.10.9Includedraft XeH Laboratory Report (wip)2020‑10‑24 18:01:42
RelationshipSpecialization: template 2.16.840.1.113883.10.12.101 CDA recordTarget (2005‑09‑07)
ref
ad1bbr-
Example
Human Patient Example a
<recordTarget typeCode="RCT">
  <patientRole classCode="PAT">
    <id extension="sw54321" root="1.3.6.1.4.1.19376.1.3.4"/>    <addr>
      <streetAddressLine>1313 Mockingbird Lane</streetAddressLine>      <city>Janesville</city>      <state>WI</state>      <postalCode>53545</postalCode>      <country>USA</country>    </addr>
    <telecom value="tel: 608-555-5555"/>    <patient classCode="PSN">
      <name>
        <family>Winters</family>        <given>Shelly</given>      </name>
      <administrativeGenderCode code="F"/>      <birthTime value="19401213000000.0000-0500"/>    </patient>
  </patientRole>
</recordTarget>
Example
Human Patient Example b: In the event a unit of information about the patient is not known or has been de-identified, the use of nullFlavor is appropriate
<recordTarget typeCode="RCT">
  <patientRole classCode="PAT">
    <id extension="sw54321" root="1.3.6.1.4.1.19376.1.3.4"/>    <addr>
      <streetAddressLine nullFlavor="MSK"/>      <!-- masked value -->
      <city nullFlavor="MSK"/>      <!-- masked value -->
      <state nullFlavor="MSK"/>      <!-- masked value -->
      <postalCode>53545</postalCode>      <country>USA</country>    </addr>
    <telecom nullFlavor="UNK"/>    <!-- unknown value -->
    <patient classCode="PSN">
      <name nullFlavor="MSK"/>      <!-- masked value -->
      <administrativeGenderCode code="F"/>      <birthTime value="19401213000000.0000-0500"/>    </patient>
  </patientRole>
</recordTarget>
ItemDTCardConfDescriptionLabel
hl7:recordTarget
1 … *RHumadotsrget
hl7:patientRole
1 … 1RHumadotsrget
hl7:id
II1 … *RHumadotsrget
hl7:addr
AD1 … *All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.Humadotsrget
hl7:telecom
TEL1 … *All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.Humadotsrget
hl7:patient
1 … 1Humadotsrget
hl7:id
II0 … 1Humadotsrget
hl7:name
PN1 … *Humadotsrget
hl7:administrativeGenderCode
CE1 … 1RHumadotsrget
hl7:birthTime
TS1 … 1RHumadotsrget