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Template Laboratory Report Data Processing Entry NL 2022‑03‑30

Id2.16.840.1.113883.2.4.3.11.60.25.10.53
ref
zib2020bbr-
Effective Date2022‑03‑30
Statusdraft DraftVersion Label2020
NameLaboratoryReportDataProcessingEntryDisplay NameLaboratory Report Data Processing Entry NL
Description
nl-NL 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 bevat exact één act element. 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 resultaten 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. Wijzigingen in versie 2022-03-30T00:00:00:
  • Toegevoegd: entryRelationship 0..1 ResultStatus (template 2.16.840.1.113883.2.4.3.11.60.121.10.55)
  • Toegevoegd: entryRelationship 0..1 Kopie-indicator (template 2.16.840.1.113883.2.4.3.11.60.20.77.10.9200)
  • Toegevoegd: entryRelationship 0..1 MEDLAB IDE+2 (template 2.16.840.1.113883.2.4.3.11.60.121.10.53)

en-US 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. Changes in version 2022-03-30T00:00:00:
  • Added: entryRelationship 0..1 ResultStatus (template 2.16.840.1.113883.2.4.3.11.60.121.10.55)
  • Added: entryRelationship 0..1 Copy-indicator (template 2.16.840.1.113883.2.4.3.11.60.20.77.10.9200)
  • Added: entryRelationship 0..1 MEDLAB IDE+2 (template 2.16.840.1.113883.2.4.3.11.60.121.10.53)
ContextSibling nodes of template element with id 2.16.840.1.113883.2.4.3.11.60.25.10.53
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 5 templates, Uses 18 templates
Used by as NameVersion
2.16.840.1.113883.2.4.3.11.60.121.4.2.13.1Transactionfinal nl-NL Registratie
en-US Registration		2020‑09‑01
2.16.840.1.113883.2.4.3.11.60.25.10.51linkdraft Lab2Zorg - Sharing Laboratory Reports NL (XD-LAB) (2020)2022‑03‑30
2.16.840.1.113883.2.4.3.11.60.25.10.52Containmentdraft Laboratory Specialty Section NL (2020)2022‑03‑30
2.16.840.1.113883.2.4.3.11.60.25.10.54Containmentdraft Laboratory Report Item Section NL (2020)2022‑03‑30
2.16.840.1.113883.2.4.3.11.60.66.10.77Containmentdraft Organizer Labbepalingen2022‑03‑30
2.16.840.1.113883.2.4.3.11.60.121.10.51linkactive Laboratory organizer or CDA2022‑03‑30
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.1.1Containmentactive Notification Organizer (2017)DYNAMIC
1.3.6.1.4.1.19376.1.3.1.1.1Containmentactive Notifiable Condition (2017)DYNAMIC
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
1.3.6.1.4.1.19376.1.3.1.3Containmentactive Specimen Received (2017)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 Performer (2017)DYNAMIC
1.3.6.1.4.1.19376.1.3.10.9.2Containmentactive Multimedia Embedded Content (2017)DYNAMIC
2.16.840.1.113883.2.4.3.11.60.7.10.2Containmentdraft Laboratory Battery Organizer NL (Specimen) (2020)2022‑03‑30
2.16.840.1.113883.2.4.3.11.60.7.10.3Containmentpending Specimen Collection HCIM2022‑03‑30
2.16.840.1.113883.2.4.3.11.60.7.10.4Containmentdraft Laboratory Isolate Organizer NL (Specimen) (2020)2022‑03‑30
2.16.840.1.113883.2.4.3.11.60.7.10.31Containmentdraft Laboratory Observation NL (2020)2022‑03‑30
2.16.840.1.113883.2.4.3.11.60.20.77.10.9200Containmentactive Kopie-indicator (9)2018‑01‑12 10:18:47
2.16.840.1.113883.2.4.3.11.60.121.10.53Containmentdraft MEDLAB 1.0 IDE+2 Identificatie materiaal/aanvraag (2020)2022‑03‑30
2.16.840.1.113883.2.4.3.11.60.121.10.55Containmentdraft ResultStatus (2020)2022‑03‑30
2.16.840.1.113883.2.4.3.11.60.121.10.58Containmentdraft IHE Comment Entry NL (2020)2022‑03‑30
RelationshipVersion: template 2.16.840.1.113883.2.4.3.11.60.25.10.53 Laboratory Report Data Processing Entry (2021‑10‑27)
ref
zib2017bbr-

Specialization: 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="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">
    <!-- 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>
Example
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>
ItemDTCardConfDescriptionLabel
hl7:templateId
II1 … 1MLabodotsntry
@root
uid1 … 1F2.16.840.1.113883.2.4.3.11.60.25.10.53
hl7:templateId
II1 … 1MLabodotsntry
@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.1
hl7:act
1 … 1nl-NL 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 (vooralsnog geen NL use case)
  • Notifiable Condition (vooralsnog geen NL use case)
  • Case Identifier (vooralsnog geen NL use case)
  • Outbreak Identifier (vooralsnog geen NL use case)
  • Laboratory Isolate Organizer
  • Laboratory Battery Organizer
  • Laboratory Observation
  • Mutimedia Embedded Content (vooralsnog geen NL use case)
  • Annotation Comment (vooralsnog geen NL use case)

en-US There 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 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 (no Dutch use case identified yet)
  • Notifiable Condition (no Dutch use case identified yet)
  • Case Identifier (no Dutch use case identified yet)
  • Outbreak Identifier (no Dutch use case identified yet)
  • Laboratory Isolate Organizer
  • Laboratory Battery Organizer
  • Laboratory Observation
  • Mutimedia Embedded Content (no Dutch use case identified yet)
  • Annotation Comment (no Dutch use case identified yet)
Labodotsntry
@classCode
cs1 … 1FACT
@moodCode
cs1 … 1FEVN
hl7:code
CD1 … 1Men-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.
Labodotsntry
hl7:statusCode
CS1 … 1Men-US The statusCode has required terminology. The zib compliant terminology may be found under entryRelationship/observation[templateId/@root = '2.16.840.1.113883.2.4.3.11.60.121.10.55']. ‘completed’ when the order has been fulfilled.
'active' when at least test is not ready/signed off yet
‘aborted’ if the order will not be fulfilled.
Mapping with zib-terminology
zib statusCode remark
pending active Normally only relevant in placer/filler communication
preliminary active Normally only relevant in placer/filler communication
final completed
appended completed This status only means something if it is known what result this result appends. This is only possible in a higher context. For example through ClinicalDocument/relatedDocument[@typeCode = 'APND']
corrected completed This status only means something is it is known what result it is a correction to. The best match is through observation/id
aborted Zib does not support this status. Only relevant in placer/filler communication

nl-NL De statusCode heeft verplichte terminologie. De zib-conforme terminologie komt onder entryRelationship/observation[templateId/@root = '2.16.840.1.113883.2.4.3.11.60.121.10.55']. ‘completed’ als het resultaat compleet is.
'active' als tenminste een deel van het resultaat er nog niet is
‘aborted’ als het resultaat niet meer zal komen.
Mapping met zib-terminologie
zib statusCode opmerking
pending active Normaal alleen relevant in verkeer tussen aanvrager en uitvoerder (lab)
preliminary active Normaal alleen relevant in verkeer tussen aanvrager en uitvoerder (lab)
final completed
appended completed Betekent alleen iets als bekend is waarop dit resultaat een aanvulling is. Dat kan alleen in overkoepelende context worden geduid. Bijvoorbeeld in ClinicalDocument/relatedDocument[@typeCode = 'APND']
corrected completed Betekent alleen iets als bekend is waarop dit resultaat een correctie is. De beste manier om tot een match te komen is via overeenkomstige observation/id
aborted Zib ondersteunt deze status niet. Alleen relevant in verkeer tussen aanvrager en uitvoerder (lab)
Labodotsntry
 CONF
@code shall be "completed"
or
@code shall be "active"
or
@code shall be "aborted"
Choice0 … 1Elements to choose from:
hl7:subject
0 … 1en-US subject 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)		Labodotsntry
@typeCode
cs0 … 1FSBJ
hl7:subject
0 … 1en-US subject 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)		Labodotsntry
@typeCode
cs0 … 1FSBJ
hl7:performer
0 … *en-US 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)		Labodotsntry
@typeCode
cs0 … 1FPRF
hl7:author
0 … *en-US author used if different from the author of the header, to supersede it for this section.Labodotsntry
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.

Contains 1.3.6.1.4.1.19376.1.3.3.1.5 Laboratory Results Validator (DYNAMIC)		Labodotsntry
where [@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.
Labodotsntry
where [@typeCode='RESP']
@typeCode
cs1 … 1FRESP
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).
Labodotsntry
where [@typeCode='DEV']
@typeCode
cs1 … 1FDEV
hl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.1.1 Notification Organizer (DYNAMIC)Labodotsntry
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 2.16.840.1.113883.2.4.3.11.60.7.10.3 Specimen Collection HCIM (2022‑03‑30)Labodotsntry
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.1.3 Specimen Received (DYNAMIC)Labodotsntry
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 2.16.840.1.113883.2.4.3.11.60.7.10.2 Laboratory Battery Organizer NL (Specimen) (2022‑03‑30)Labodotsntry
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 2.16.840.1.113883.2.4.3.11.60.7.10.4 Laboratory Isolate Organizer NL (Specimen) (2022‑03‑30)Labodotsntry
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 2.16.840.1.113883.2.4.3.11.60.7.10.31 Laboratory Observation NL (2022‑03‑30)Labodotsntry
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 2.16.840.1.113883.2.4.3.11.60.121.10.58 IHE Comment Entry NL (2022‑03‑30)Labodotsntry
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.1.1.1 Notifiable Condition (DYNAMIC)Labodotsntry
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.1.1.2 Case Identification (DYNAMIC)Labodotsntry
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.1.1.3 Outbreak Identification (DYNAMIC)Labodotsntry
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.10.9.2 Multimedia Embedded Content (DYNAMIC)Labodotsntry
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … 1Rnl-NL Kopie-indicator. Alleen gebruiken als deze bouwsteen en onderliggende bouwstenen van een andere bron komen. Deze indicator kan ook op (bundles van) individuele resultaten worden gebruikt indien sommige resultaten van een andere bron komen
en-US Copy-indicator. Use only when this result and child results are from a different source. This indicator is also possible on (bundles of) individual results in case some results are from a different source
Contains 2.16.840.1.113883.2.4.3.11.60.20.77.10.9200 Kopie-indicator (2018‑01‑12 10:18:47)		Labodotsntry
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … 1Rnl-NL MEDLAB IDE+2 referentie. Alleen gebruiken als deze bouwsteen en onderliggende bouwstenen uit betreffende MEDLAB bericht komen. Deze indicator kan ook op (bundles van) individuele resultaten worden gebruikt indien sommige resultaten van een specifiek MEDLAB bericht komen
en-US MEDLAB IDE+2 reference. Use only when this result and child results are from the MEDLAB message with this reference. This indicator is also possible on (bundles of) individual results in case some results from a specific MEDLAB message
Contains 2.16.840.1.113883.2.4.3.11.60.121.10.53 MEDLAB 1.0 IDE+2 Identificatie materiaal/aanvraag (2022‑03‑30)		Labodotsntry
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … 1Rnl-NL ResultaatStatus
en-US ResultaatStatus
Contains 2.16.840.1.113883.2.4.3.11.60.121.10.55 ResultStatus (2022‑03‑30)		Labodotsntry
@typeCode
cs1 … 1FCOMP
 Schematron assertrolered error 
 testhl7:entryRelationship 
 MessageA Laboratory Result Content SHALL be present.