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Template Laboratory Report Data Processing Entry_Sandbox-sm 2019‑03‑27 16:09:06

Id2.16.840.1.113883.3.1937.99.61.41.10.27Effective Date2019‑03‑27 16:09:06
Statusdraft DraftVersion Label2017
NameLaboratoryReportDataProcessingEntry_Sandbox-smDisplay NameLaboratory Report Data Processing Entry_Sandbox-sm
Description
One Laboratory Report Data Processing Entry SHALL be present in each leaf section of the report. The entry element SHALL be present and have its root attribute valued "1.3.6.1.4.1.19376.1.3.1". The entry SHALL contain a single act sub-element. This act is hereafter referred to as the Specimen Act. All other CDA level 3 content modules are nested in this one act. The Specimen Act shall contain at least one Laboratory Observation. If all observations of the entry have been produced on the same specimen, this specimen SHALL be attached to the top Specimen Act as a specimen sub-element.
A particular section of the laboratory report MAY carry results more confidential than the rest of the report (e.g. the section of the HIV serology). This is expressed with the confidentialityCode sub-element of the Specimen Act.
The Laboratory Report Data Processing Entry SHALL conform to statements here and those made in the following tables and sections.
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
ssmith-dataelement-243draft  draft SMITH Sandbox
ssmith-dataelement-245draft  draft SMITH Sandbox
ssmith-dataelement-244draft  draft SMITH Sandbox
Used by / Uses
Used by 0 transactions and 0 templates, Uses 15 templates
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.1.1Containmentactive Notification OrganizerDYNAMIC
1.3.6.1.4.1.19376.1.3.1.1.1Containmentactive Notification ConditionDYNAMIC
1.3.6.1.4.1.19376.1.3.1.1.2Containmentactive Case Identification (2017)DYNAMIC
1.3.6.1.4.1.19376.1.3.1.1.3Containmentactive Outbreak Identification (2017)DYNAMIC
1.3.6.1.4.1.19376.1.3.1.2Containmentactive Specimen Collection (2017)DYNAMIC
1.3.6.1.4.1.19376.1.3.1.3Containmentactive Specimen Received (2017)DYNAMIC
1.3.6.1.4.1.19376.1.3.1.4Containmentdraft Befundgruppen (Laboratory Battery Organizer)DYNAMIC
1.3.6.1.4.1.19376.1.3.1.5Containmentactive Laboratory Isolate Organizer (2017)DYNAMIC
1.3.6.1.4.1.19376.1.3.1.6Containmentdraft Laborergebnisse (Laboratory Observation)DYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.2.1Containmentactive Non-Human Subject (2017)DYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.3.1Containmentactive Human Patient with Non-Human Subject (2017)DYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.5Containmentactive Laboratory Results Validator (2017)DYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.7Containmentactive Laboratory PerformerDYNAMIC
1.3.6.1.4.1.19376.1.3.10.9.2Containmentactive Multimedia Embedded Content (2017)DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.2Containmentactive IHE Comment Entry (2014)DYNAMIC
RelationshipAdaptation: template 1.3.6.1.4.1.19376.1.3.1 Laboratory Report Data Processing Entry (2008‑08‑08)
ref
XDLAB-

Specialization: template 2.16.840.1.113883.10.12.301 CDA Act (2005‑09‑07)
ref
ad1bbr-
Example
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"/>    <effectiveTime value="200806180512"/>    <specimen typeCode="SPC">
      <specimenRole classCode="SPEC">
        <!-- .. -->
      </specimenRole>    </specimen>    <entryRelationship typeCode="COMP">
      <!-- .. -->
    </entryRelationship>    <!-- .. -->
  </act></entry>
Example
Laboratory Report Data Processing Entry within a Report Item Section
<entry typeCode="DRIV">
  <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"/>    <statusCode code="completed"/>    <effectiveTime value="200806180512"/>    <specimen typeCode="SPC">
      <specimenRole classCode="SPEC">
        <!-- .. -->
      </specimenRole>    </specimen>    <entryRelationship typeCode="COMP">
      <!-- .. -->
    </entryRelationship>    <!-- .. -->
  </act></entry>
ItemDTCardConfDescriptionLabel
hl7:templateId
II1 … 1MLabodotsx‑sm
 
target
ssmith-dataelement-243draft  draft SMITH Sandbox
@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.1
hl7:act
1 … 1There shall be one Act sub-element. This <act> is hereafter referred to as the Specimen Act. This sub-element uses the modules conforming to the following requirements. These modules, when present, shall be recorded as <entryRelationship> elements under the Specimen Act.
  • Specimen Collection 1.3.6.1.4.1.19376.1.3.1.2
  • 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
Labodotsx‑sm
@classCode
cs1 … 1FACT
@moodCode
cs1 … 1FEVN
hl7:code
CD1 … 1M
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.
Labodotsx‑sm
 
target
ssmith-dataelement-244draft  draft SMITH Sandbox
hl7:statusCode
CS1 … 1MMandatory.
  • ‘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.
Labodotsx‑sm
 
target
ssmith-dataelement-245draft  draft SMITH Sandbox
 CONF
@code shall be "completed"
or
@code shall be "active"
or
@code shall be "aborted"
Choice0 … 1Elements to choose from:
hl7:subject
0 … 1subject in case of a non-human subject
Contains 1.3.6.1.4.1.19376.1.3.3.1.2.1 Non-Human Subject (DYNAMIC)		Labodotsx‑sm
@typeCode
cs0 … 1FSBJ
hl7:subject
0 … 1subject in case of a non-human subject
Contains 1.3.6.1.4.1.19376.1.3.3.1.3.1 Human Patient with Non-Human Subject (DYNAMIC)		Labodotsx‑sm
@typeCode
cs0 … 1FSBJ
hl7:performer
0 … *performer participation used if different from the performer of the header, to supersede it for this section.
Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC)		Labodotsx‑sm
@typeCode
cs0 … 1FPRF
hl7:author
0 … *author used if different from the author of the header, to supersede it for this section.Labodotsx‑sm
hl7:participant
0 … *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.

Contains 1.3.6.1.4.1.19376.1.3.3.1.5 Laboratory Results Validator (DYNAMIC)		Labodotsx‑sm
where [@typeCode='AUTHEN']
hl7:participant
0 … *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.
Labodotsx‑sm
where [@typeCode='RESP']
@typeCode
cs1 … 1FRESP
hl7:participant
0 … *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).
Labodotsx‑sm
where [@typeCode='DEV']
@typeCode
cs1 … 1FDEV
hl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.1.1 Notification Organizer (DYNAMIC)Labodotsx‑sm
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.1.2 Specimen Collection (DYNAMIC)Labodotsx‑sm
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.1.3 Specimen Received (DYNAMIC)Labodotsx‑sm
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.1.4 Befundgruppen (Laboratory Battery Organizer) (DYNAMIC)Labodotsx‑sm
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.1.5 Laboratory Isolate Organizer (DYNAMIC)Labodotsx‑sm
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.1.6 Laborergebnisse (Laboratory Observation) (DYNAMIC)Labodotsx‑sm
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (DYNAMIC)Labodotsx‑sm
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.1.1.1 Notification Condition (DYNAMIC)Labodotsx‑sm
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.1.1.2 Case Identification (DYNAMIC)Labodotsx‑sm
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.1.1.3 Outbreak Identification (DYNAMIC)Labodotsx‑sm
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.10.9.2 Multimedia Embedded Content (DYNAMIC)Labodotsx‑sm
@typeCode
cs1 … 1FCOMP
 Schematron assertrolered error 
 testhl7:entryRelationship 
 MessageA Laboratory Result Content SHALL be present.