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Template Laboratory Speciality Section 2017‑03‑16 23:57:18

Id2.16.756.5.30.1.1.10.3.3
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ch-palm-
Effective Date2017‑03‑16 23:57:18
Statusdraft DraftVersion Label2017
Namechpalm_section_LaboratorySpecialtyDisplay NameLaboratory Speciality Section
Description
Chapter (CDA Body Section) with laboratory results according to Sharing Laboratory Reports (XD-LAB) Content Module, IHE PaLM Technical Framework Revision 7.0 - July 5, 2016.
Each Laboratory Specialty Section contains laboratory tests of a particular discipline (e.g., microbiology or serology).
The Laboratory Specialty Section uses LOINC codes to define the appropriate discipline. Laboratory Specialty Sections MUST NOT be nested.
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.
  • Choice 2: Text and Entry
    With this option, the examination results MUST be documented in the text element of the section and the corresponding entry element (Laboratory Data Processing Entry).
    The human-readable text MUST be generated automatically from the entry and its sub-elements.
    For this purpose the presentation options according to the CDA Narrative Block schema (NarrativeBlock.xsd) may be used: tables, lists, paragraphs, hyperlinks, footnotes, references to attached or embedded multimedia objects.
If a document contains multiple Laboratory Specialty Sections, Choice 1 or Choice 2 can be selected for each individual chapter.
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
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ad1bbr-

Specialization: template 1.3.6.1.4.1.19376.1.3.3.2.1 Laboratory Specialty Section (2008‑08‑08)
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XDLAB-
Example
Specialty Section that holds a leaf section and Leaf Section that holds one Report Item
<section classCode="DOCSECT">
  <templateId root="1.3.6.1.4.1.19376.1.3.3.2.1"/>  <code code="18723-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HEMATOLOGY STUDIES"/>  <title>Laborbefund - Hämatologie</title>  <component>
    <section>
      <templateId root="1.3.6.1.4.1.19376.1.3.3.2.2"/>      <!-- Leaf Section that holds one Report Item -->
    </section>
  </component>
</section>
Example
Specialty Section that holds Report Items directly as a Laboratory Report Data Processing Entry
<section classCode="DOCSECT">
  <templateId root="1.3.6.1.4.1.19376.1.3.3.2.1"/>  <code code="18719-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="CHEMISTRY STUDIES"/>  <title>Laborbefund - Chemie</title>  <text/>  <entry typeCode="DRIV">
    <templateId root="1.3.6.1.4.1.19376.1.3"/>    <act classCode="ACT" moodCode="EVN"> ... </act>  </entry>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
chpadotsalty
hl7:templateId
II1 … 1Mchpadotsalty
@root
uid1 … 1F2.16.756.5.30.1.1.10.3.3
hl7:templateId
II1 … 1Mchpadotsalty
@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.3.2.1
hl7:code
CE1 … 1MThis declares the laboratory discipline of the section. chpadotsalty
@code
1 … 1R
@codeSystem
oid1 … 1F2.16.840.1.113883.6.1
@codeSystemName
st1 … 1FLOINC
@displayName
1 … 1RThe displayName of the code MUST be specified for tracking purposes. However, processing is NOT ALLOWED. Instead, a processing system is to display a user readable language translation of the code from the value set.
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.1 Laboratory Specialties (DYNAMIC)
hl7:title
ST1 … 1R The title of the chapter MUST be specified and correspond to the following text format, where <human readable code> contains the corresponding translation of the document LOINC code:
  • [ge]: 'Laborbefund - <human readable code>'
  • [fr]: 'Rapport de laboratoire - <human readable code>'
  • [it]: 'Referto di laboratorio - <human readable code>'
  • [en]: 'Laboratory Specialty - <human readable code>'

The following translations of the LOINC codes given in XD-LAB MUST be used:
LOINC CodeText
18717-9[ge]: Immunhämatologie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18718-7[ge]: Molekularbiologie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18719-5[ge]: Chemie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18720-3[ge]: Gerinnung
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18721-1[ge]: Medikamente
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18722-9[ge]: Fertilität
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18723-7[ge]: Hämatologie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18724-5[ge]: HLA
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18725-2[ge]: Mikrobiologie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18727-8[ge]: Serologie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18728-6[ge]: Toxikologie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18729-4[ge]: Urin Untersuchungen
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18767-4[ge]: Blutgase
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18768-2[ge]: Differenzialblutbild
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18769-0[ge]: Antibiogramme
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
26435-8[ge]: Molekulare Pathologie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
26436-6[ge]: Laboruntersuchungen
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
26437-4[ge]: Stimulationen
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
26438-2[ge]: Zytologie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
chpadotsalty
 Example
Deutsch
<title>Laborbefund - Immunhämatologie</title>
 Example
Englisch
<title>Laboratory Specialty - Blood Bank Studies</title>
Choice1 … *Elements to choose from:
hl7:component
0 … *CContains 2.16.756.5.30.1.1.10.3.5 Laboratory Report Item Section - coded (DYNAMIC)chpadotsalty
hl7:entry
0 … *CContains 2.16.756.5.30.1.1.10.4.4 Laboratory Report Data Processing Entry (DYNAMIC)chpadotsalty
@typeCode
cs1 … 1FDRIV
 Schematron assertrolered error 
 test(hl7:component and not(hl7:text or hl7:entry)) or (not(hl7:component) and hl7:text and hl7:entry) 
 MessageA 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.