chpalm_section_LaboratorySpecialtyCoded

Template Laboratory Speciality Section - coded 2019‑08‑20

2.16.756.5.30.1.1.10.3.3

ref

ch-palm-

Effective Date

2019‑08‑20

Status

Active

Version Label

2019

Name

chpalm_section_LaboratorySpecialtyCoded

Display Name

Laboratory Speciality Section - coded

Description

Chapter (CDA Body Section) with laboratory results according to Sharing Laboratory Reports (XD-LAB) Content Module, IHE PaLM Technical Framework Revision 10.0 - August 20, 2019.
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.

Context

Parent nodes of template element with id 2.16.756.5.30.1.1.10.3.3

Label

IHE PalM TF3 Rev.10, 6.3.3.1

Classification

CDA Section Level Template

Open/Closed

Open (other than defined elements are allowed)

Used by / Uses

Used by 3 transactions and 3 templates, Uses 2 templates

Used by	as	Name	Version
2.16.756.5.30.1.127.77.1.4.5	Transaction	CDA-CH-VACD - Immunization Recommendation Request (2018)	2018‑04‑10 18:08:44
2.16.756.5.30.1.127.77.1.4.6	Transaction	CDA-CH-VACD - Immunization Recommendation Response (2018)	2018‑04‑10 18:09:59
2.16.756.5.30.1.127.77.1.4.7	Transaction	CDA-CH-VACD - Vaccination Record (2018)	2018‑04‑10 18:10:49
2.16.756.5.30.1.1.10.1.17	Containment	Immunization Recommendation Request (2020)	2020‑06‑26
2.16.756.5.30.1.1.10.1.18	Containment	Immunization Recommendation Response (2020)	2020‑06‑26
2.16.756.5.30.1.1.10.1.19	Containment	Vaccination Record (2020)	2020‑06‑26
Uses	as	Name	Version
2.16.756.5.30.1.1.10.3.5	Containment	Laboratory Report Item Section - coded (2019)	DYNAMIC
2.16.756.5.30.1.1.10.4.4	Containment	Laboratory Report Data Processing Entry (2019)	DYNAMIC

Relationship

Specialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)

ref

ad1bbr-

Specialization: template 1.3.6.1.4.1.19376.1.3.3.2.1 Laboratory Specialty Section (2008‑08‑08)

ref

XDLAB-

Example

Specialty Section that holds a leaf section and Leaf Section that holds one Report Item

<section classCode="DOCSECT">
  <templateId root="2.16.756.5.30.1.1.10.3.3"/>  <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"/>      
    </section>  </component></section>

Example

Specialty Section that holds Report Items directly as a Laboratory Report Data Processing Entry

<section classCode="DOCSECT">
<templateId root="2.16.756.5.30.1.1.10.3.3"/> <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>narrative text</text> <entry typeCode="DRIV">
<templateId root="1.3.6.1.4.1.19376.1.3"/> <act classCode="ACT" moodCode="EVN"> ... </act> </entry></section>

Item

Card

Conf

Description

Label

hl7:section

IHE PalM TF3 Rev.10, 6.3.3.1

hl7:templateId

1 … 1

IHE PalM TF3 Rev.10, 6.3.3.1

@root

uid

1 … 1

2.16.756.5.30.1.1.10.3.3

hl7:templateId

1 … 1

IHE PalM TF3 Rev.10, 6.3.3.1

@root

uid

1 … 1

1.3.6.1.4.1.19376.1.3.3.2.1

hl7:id

0 … 1

An ID for this section MAY be filled for traceability.

IHE PalM TF3 Rev.10, 6.3.3.1

@root

uid

1 … 1

MUST contain the OID of the system that issued the ID. OIDs of code systems, which are published in the public OID registry for the Swiss health care system (oid.refdata.ch) are REQUIRED. Others are NOT ALLOWED.

@extension

0 … 1

Contains the ID itself. The ID MUST be unique within the system that issued the ID.

hl7:code

1 … 1

This declares the laboratory discipline of the section.

IHE PalM TF3 Rev.10, 6.3.3.1

@code

1 … 1

@codeSystem

oid

1 … 1

2.16.840.1.113883.6.1

@codeSystemName

1 … 1

LOINC

@displayName

1 … 1

The 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

1 … 1

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 Code	Text
18717-9	[ge]: Immunhämatologie [fr]: Immunohématologie [it]: Immunoematologia
18718-7	[ge]: Molekularbiologie [fr]: Biologie moléculaire [it]: Biologia molecolare
18719-5	[ge]: Chemie [fr]: Chimie [it]: Chimica
18720-3	[ge]: Gerinnung [fr]: Coagulation [it]: Coagulazione
18721-1	[ge]: Medikamente [fr]: Médicaments [it]: Medicamenti
18722-9	[ge]: Fertilität [fr]: Fertilité [it]: Fertilità
18723-7	[ge]: Hämatologie [fr]: Hématologie [it]: Ematologia
18724-5	[ge]: HLA [fr]: HLA [it]: HLA
18725-2	[ge]: Mikrobiologie [fr]: Microbiologie [it]: Microbiologia
18727-8	[ge]: Serologie [fr]: Sérologie [it]: Sierologia
18728-6	[ge]: Toxikologie [fr]: Toxicologie [it]: Tessicologia
18729-4	[ge]: Urin Untersuchungen [fr]: Analyses dans l'urine [it]: Analisi nelle urine
18767-4	[ge]: Blutgase [fr]: Gazométrie [it]: Gasometria
18768-2	[ge]: Differenzialblutbild [fr]: Répartition leucocytaire [it]: Differenziazione leucocitaria
18769-0	[ge]: Antibiogramme [fr]: Antibiogramme [it]: Antibiogramma
26435-8	[ge]: Molekulare Pathologie [fr]: Pathologie moleculaire [it]: Patologia moleculare
26436-6	[ge]: Laboruntersuchungen [fr]: Études de laboratoire [it]: Esami di laboratorio
26437-4	[ge]: Stimulationen [fr]: Stimulation [it]: Stimolazione
26438-2	[ge]: Zytologie [fr]: Cytologie [it]: Citologia

IHE PalM TF3 Rev.10, 6.3.3.1

Example

Deutsch

<title>Laborbefund - Immunhämatologie</title>

Example

Englisch

<title>Laboratory Specialty - Blood Bank Studies</title>

Variable let

Name

languageCode

Value

substring(/hl7:ClinicalDocument/hl7:languageCode/@code,1,2)

Schematron assert

role

error

test

not($languageCode='en') or starts-with(text(),'Laboratory report')

Message

The English title must start with 'Laboratory report'

Schematron assert

role

error

test

not($languageCode='de') or starts-with(text(),'Laborbefund')

Message

The German title must start with 'Laborbefund'

Schematron assert

role

error

test

not($languageCode='fr') or starts-with(text(),'Rapport de laboratoire')

Message

The French title must start with 'Rapport de laboratoire'

Schematron assert

role

error

test

not($languageCode='it') or starts-with(text(),'Rapporto di laboratorio')

Message

The Italian title must start with 'Rapporto di laboratorio'

hl7:text

SD.TEXT

0 … 1

The narrative text for this section.

IHE PalM TF3 Rev.10, 6.3.3.1

Choice

1 … *

Elements to choose from:

hl7:component containing template 2.16.756.5.30.1.1.10.3.5 Laboratory Report Item Section - coded (DYNAMIC)
hl7:entry containing template 2.16.756.5.30.1.1.10.4.4 Laboratory Report Data Processing Entry (DYNAMIC)

hl7:component

0 … *

Contains 2.16.756.5.30.1.1.10.3.5 Laboratory Report Item Section - coded (DYNAMIC)

IHE PalM TF3 Rev.10, 6.3.3.1

hl7:entry

0 … *

The narrative text in the text element of the section MUST be generated automatically from the information in this entry.
Contains 2.16.756.5.30.1.1.10.4.4 Laboratory Report Data Processing Entry (DYNAMIC)

IHE PalM TF3 Rev.10, 6.3.3.1

@typeCode

1 … 1

DRIV

Schematron assert

role

error

test

(hl7:component and not(hl7:text or hl7:entry)) or (not(hl7:component) and hl7:text and hl7:entry)

Message

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.

Template
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Template

Template Laboratory Speciality Section - coded 2019‑08‑20