Content Modules for CDA Header (Level 1): Laboratory Performer template in the CDA header (ClinicalDocument/documentationOf/serviceEvent)

ClinicalDocument/documentationOf(s) MAY be present. The documentationOf/serviceEvent represents the main Act being documented, that is an act of reporting Result Event(s) produced by a laboratory.

Use of sub element documentationOf/serviceEvent/effectiveTime to document the time boundaries of events in the document is appropriate.

This laboratory report content module adds the optional sub element documentationOf/serviceEvent/statusCode to enable the sharing of non-final reports. A report is considered as non-final (e.g., a preliminary report) if and only if it documents an Act, which is still in the status “active” (i.e., serviceEvent/statusCode@code=”active”).

The statusCode sub element is an extension to the CDA R2 schema. This sub-element is optional. When it is not there, the documented Act is assumed to be completed and the report is assumed to be a final report.