Id2.16.840.1.113883.2.51.10.33Effective Date2021‑10‑01 11:41:22
Statusactive ActiveVersion Label1.0
NameXeHLabReportDisplay NameXeH Laboratory Result Report
Description

Sharing Laboratory Reports (XD-LAB) Content Module

This Content Integration Profile describes a laboratory report as an electronic document to be published towards a document sharing resource such as an Electronic Health Record (EHR) or Personal Health Record (PHR) shared by a community of care providers, using one of the document sharing profiles defined in ITI-TF.

Such an electronic document contains the set of releasable results produced by a clinical laboratory or by a public health laboratory in fulfillment of an Order or an Order Group for a patient. The report is shared in a human-readable format. In addition, this electronic laboratory report SHALL contain test results in a machine-readable format, to facilitate the integration of these observations in the database of a consumer system.

The human rendering of the laboratory report defined in this Integration Profile is compatible with laboratory regulations in numerous countries, including CLIA in the USA, GBEA in France.

The laboratory report described in this profile, with its set of test results in a machine-readable format, MAY also be used to share historical results with appropriate content anonymization and patient identification pseudonymization to create shared distributed repositories of laboratory information.

ContextPathname /
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 22 templates
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.2Includeactive Non-Human Subject (2017)DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7Containmentactive IHE Payers section (2014)DYNAMIC
2.16.840.1.113883.2.51.10.5Includeactive XeH CDA author (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.6Includeactive XeH CDA custodian (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.7Includeactive XeH CDA dataEnterer (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.8Includeactive XeH CDA legalAuthenticator (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.9Includeactive XeH CDA recordTarget (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.11Includeactive XeH inFulfillmentOf (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.14Includeactive XeH Information Recipient (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.23Containmentactive XeH Problems Section (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.34Containmentactive XeH Laboratory Specialty Section, Variant 1 (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.44Includeactive XeH Results Validator (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.47Includeactive XeH Lab DocumentationOf (2017)DYNAMIC
2.16.840.1.113883.2.51.10.48Includeactive XeH Ordering Provider (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.53Includeactive XeH CDA recordTarget with non-human Subject (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.54Containmentactive XeH Laboratory Specialty Section, Variant 2 (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.58Containmentactive XeH Annotation Comment (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.71Includeactive XeH Lab ComponentOf (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.82Containmentactive XeH Vital Signs Section (1.0)DYNAMIC
2.16.840.1.113883.2.51.10.94Containmentactive XeH Coded Reason for Referral Section (1.0)DYNAMIC
2.16.840.1.113883.10.22.2.7Includepending IPS CDA relatedDocument (STU1)DYNAMIC
2.16.840.1.113883.10.22.3.11Containmentpending IPS History of Pregnancy Section (TI-2020)DYNAMIC
RelationshipAdaptation: template 1.3.6.1.4.1.19376.1.3.3 Sharing Laboratory Reports (XD-LAB) Content Module (2016‑07‑05)
ref
XDLAB-

Adaptation: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
XeHLdotsport
hl7:realmCode
CS0 … 1R

This attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question. This element should not be used for identifying the originating country.

XeHLdotsport
 Example
Example for a French extension
<realmCode code="FR"/>
hl7:typeId
II1 … 1M

This element is a technology-neutral explicit reference to the standard CDA R2. It SHALL be present and valued as follows:
ClinicalDocument/typeId@root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models);
ClinicalDocument.typeId@extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description).

XeHLdotsport
@root
uid1 … 1F2.16.840.1.113883.1.3
@extension
st1 … 1FPOCD_HD000040
hl7:templateId
II1 … 1M

This element is identifying the set of constraints applied to the CDA R2 standard by this specification of a laboratory report. 

XeHLdotsport
@root
uid1 … 1F2.16.840.1.113883.2.51.10.33
hl7:templateId
II1 … 1M

This element is identifying the set of constraints applied to the CDA R2 standard by this specification of a laboratory report. 

XeHLdotsport
@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.3
 Compliance to IHE XD-LAB template
hl7:id
II1 … 1M

ClinicalDocument/Id SHALL be present. It represents the unique instance identifier of the clinical document. The combination of the root and extension attributes SHALL provide a globally unique identifier, in accordance with CDA R2, without further constraints.

XeHLdotsport
 Example
Example using the extension attribute
<id root="1.3.6.1.4.1.19376.1.3.4" extension="abc2"/>
 Example
Example without the extension attribute
<!-- In this case the OID populated in the root attribute is the unique instance identifier itself
(The OID in this example is constructed from the OID dedicated to all examples in IHE LAB TF: 1.3.6.1.4.1.19376.1.3.4)-->
<id root="1.3.6.1.4.1.19376.1.3.4.1232669"/>
hl7:code
CE.IPS1 … 1M

ClinicalDocument/code SHALL be present.

XeHLdotsport
@code
CONF1 … 1F11502-2
@codeSystem
1 … 1F2.16.840.1.113883.6.1
@codeSystemName
1 … 1FLOINC
hl7:title
ST1 … 1MNarrative title of the document, usually shown to the user.
XeHLdotsport
xeh:documentStatus
CE.IPS (required)0 … 1XeHLdotsport
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.2.51.13.3 FHIR Diagnostic Report Status (DYNAMIC)
hl7:effectiveTime
TS.IPS.TZ1 … 1M

ClinicalDocument/effectiveTime SHALL be present. It contains the creation date & time of the laboratory report as an electronic document. In case this is a new revision replacing a previous version (identified in parentDocument), this is the date & time of the new revision.

XeHLdotsport
 Example<effectiveTime value="20080624131933.0000-0500"/>
hl7:confidentialityCode
CE.IPS1 … 1RXeHLdotsport
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)
hl7:languageCode
CS1 … 1RDocument Language Code
XeHLdotsport
 ConstraintThe two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.19 Language Code (DYNAMIC)
 Example
Example of a report authored in American English
<languageCode code="en-US"/>
 Example
Example of a report authored in French
<languageCode code="fr-FR"/>
hl7:setId
II1 … 1M

This attribute “represents an identifier that is common across all document revisions”.

In the case this instance is generated as result of one or more transformations (translation/transcoding) the setId is supposed to remain unchanged across all those transformations.

XeHLdotsport
 Example<setId root="1.3.6.1.4.1.19376.1.3.4" extension="abc2"/>
hl7:versionNumber
INT1 … 1M

An integer value used to version successive replacement documents.

XeHLdotsport
Choice1 … 1

The base XD-LAB report template covers three varieties of laboratory reports:

  • Human (patient): The document reports laboratory observations produced on specimens collected exclusively from the patient.
  • Non-Human Subject: The document reports laboratory observations produced on specimens collected from a non-human material (e.g., water, milk, etc.) or living subject (e.g., animal).
  • Human (patient) paired with Non-Human Subject: The document reports laboratory observations produced on a non-human specimen with a relationship to a human patient (e.g., peanut butter eaten by a patient, a ferret that bit a patient).

This template limits the choice to Human subjects.

Elements to choose from:
Included0 … 1R from 2.16.840.1.113883.2.51.10.9 XeH CDA recordTarget (DYNAMIC)

Human (patient): The document reports laboratory observations produced on specimens collected exclusively from the patient.

All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.

hl7:recordTarget
0 … 1RXeHCdotsrget
@typeCode
cs0 … 1FRCT
@contextControlCode
cs0 … 1FOP
 Example<recordTarget typeCode="RCT" contextControlCode="OP">
  <patientRole classCode="PAT">
    <id root="1.2.3.999" extension="__example only__"/>    <addr>
      <streetAddressLine>HSE M CASSAR STR</streetAddressLine>      <city>ISLA</city>      <country>MT</country>    </addr>
    <telecom use="HP" value="tel:+356124567891"/>    <telecom use="WP" value="mailto:elif@foo.too.mt"/>    <patient>
      <name>
        <family>BORG</family>        <given>TANIA</given>      </name>
      <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female"/>      <birthTime value="19430130"/>      <!-- Optional guardian information ; see example below-->
      <!-- Optional languageCommunication information see example below -->
    </patient>
  </patientRole>
</recordTarget>
hl7:patientRole
1 … 1MXeHCdotsrget
@classCode
cs0 … 1FPAT
hl7:id
II1 … *RPatient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number)XeHCdotsrget
hl7:addr
AD.IPS1 … *RThe patient address.XeHCdotsrget
 ConstraintWhen used for cross-border exchange the country address part has to be provided.
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
@nullFlavor
cs0 … 1FNI
 ConstraintSHALL NOT have mixed content except for white space
If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
 Schematron assertrolered error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
hl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address LineIPSAdotsress
 Schematron assertrolered error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MessageIf the address line is included either the city or the zip code has to be provided 
hl7:city
ADXP0 … 1CSubject's or Organization's CityIPSAdotsress
hl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal CodeIPSAdotsress
hl7:state
ADXP0 … 1CSubject's or Organization's State or ProvinceIPSAdotsress
hl7:country
ADXP0 … 1CSubject's Country.IPSAdotsress
 ConstraintThe content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
hl7:telecom
TEL1 … *RPatient’s telecom information : e.g. telephone number, e-mail address. XeHCdotsrget
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@nullFlavor
cs0 … 1FNI
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
 Example<telecom use="HP" value="tel:+356124567891"/>
 Example<telecom use="WP" value="mailto:elif@foo.too.mt"/>
 Example<telecom nullFlavor="NI"/>
hl7:patient
1 … 1MXeHCdotsrget
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
 Example
Japanese example (Person Name)
<patient>
  <name use="IDE">
    <family>木村</family>    <given>通男</given>  </name>
  <name use="SYL">
    <family>きむら</family>    <given>みちお</given>  </name>
  <name use="ABC">
    <family>KIMURA</family>    <given>MICHIO</given>  </name>
  <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/>  <birthTime nullFlavor="UNK"/></patient>
hl7:name
PN1 … *MPatient NameXeHCdotsrget
 ConstraintThe Alphabetic representation of the name SHALL be always provided
hl7:family
1 … *RPatient's Family Name/SurnameXeHCdotsrget
hl7:given
1 … *RPatient's Given NameXeHCdotsrget
hl7:administrativeGenderCode
CE.IPS1 … 1RPatient's GenderXeHCdotsrget
@nullFlavor
cs0 … 1FUNK
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 Administrative Gender (HL7 V3) (DYNAMIC)
 Example<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female">
  <translation code="2" codeSystem="2.16.840.1.113883.3.129.1.2.21" codeSystemName="Cinsiyet" displayName="Kadın"/></administrativeGenderCode>
hl7:birthTime
TS1 … 1RPatient's Date of Birth. The patient date of birth may be a partial date such as only the year.XeHCdotsrget
hl7:guardian
0 … *R

The guardians of a patient.

Other patient contacts are described using the /ClinicalDocument/participant structure. The <associatedEntity> element defines the type of contact.

XeHCdotsrget
@classCode
cs1 … 1FGUARD
 Example<guardian classCode="GUARD">
  <code code="AUNT" displayName="tante" codeSystem="2.16.840.1.113883.5.111"/>  <addr nullFlavor="NI"/>  <telecom use="MC" value="tel:+33-12345678"/>  <guardianPerson>
    <name>
      <family>Curie</family>      <given>Marie</given>    </name>
  </guardianPerson>
</guardian>
hl7:code
CD.IPS0 … 1RThe relationship between the patient and the guardian or other contact may be recorded in the element. XeHCdotsrget
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19563 PersonalRelationshipRoleType (DYNAMIC)
hl7:addr
AD.IPS1 … *RXeHCdotsrget
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
@nullFlavor
cs0 … 1FNI
 ConstraintSHALL NOT have mixed content except for white space
If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
 Schematron assertrolered error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
hl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address LineIPSAdotsress
 Schematron assertrolered error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MessageIf the address line is included either the city or the zip code has to be provided 
hl7:city
ADXP0 … 1CSubject's or Organization's CityIPSAdotsress
hl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal CodeIPSAdotsress
hl7:state
ADXP0 … 1CSubject's or Organization's State or ProvinceIPSAdotsress
hl7:country
ADXP0 … 1CSubject's Country.IPSAdotsress
 ConstraintThe content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
hl7:telecom
TEL1 … *RGuardian’s telecom information: e.g. telephone number; e-mail address. XeHCdotsrget
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@nullFlavor
cs0 … 1FNI
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
hl7:guardianPerson
1 … 1RXeHCdotsrget
hl7:name
PN1 … *RPatient Guardian's NameXeHCdotsrget
hl7:family
ENXP1 … *RPatient Guardian's Family Name/SurnameXeHCdotsrget
hl7:given
ENXP1 … *RPatient Guardian's Given NameXeHCdotsrget
hl7:languageCommunication
0 … *RXeHCdotsrget
hl7:languageCode
CS1 … 1RPatient’s languageXeHCdotsrget
 ConstraintThe two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.19 Language Code (DYNAMIC)
 Example
British English
<languageCode code="en-GB"/>
 Example
Amurdak (Australia)
<languageCode code="amg-AU"/>
 Schematron assertrolered error 
 testmatches(@code,'[a-z]{2,3}-[A-Z]{2,3}') 
 MessageThe language code SHALL be in the form nn-CC or nnn-CCC, in accordance with BCP 47 (e.g. nn is the ISO language code; CC is ISO country code) 
IncludedNP from 1.3.6.1.4.1.19376.1.3.3.1.2 Non-Human Subject (DYNAMIC)

Non-Human Subject: The document reports laboratory observations produced on specimens collected from a non-human material (e.g., water, milk, etc.) or living subject (e.g., animal).

hl7:recordTarget
1 … *NPNonhdotsrget
@typeCode
cs0 … 1FRCT
@contextControlCode
cs0 … 1FOP
hl7:templateId
II1 … 1MNonhdotsrget
@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.3.1.2
hl7:patientRole
1 … 1RNonhdotsrget
@classCode
cs0 … 1FPAT
hl7:id
II1 … *RNonhdotsrget
hl7:patient
1 … 1Nonhdotsrget
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
@nullFlavor
cs1 … 1FOTH
Included0 … 1R from 2.16.840.1.113883.2.51.10.53 XeH CDA recordTarget with non-human Subject (DYNAMIC)

Human (patient) paired with Non-Human Subject: The document reports laboratory observations produced on a non-human specimen with a relationship to a human patient (e.g., peanut butter eaten by a patient, a ferret that bit a patient).

hl7:recordTarget
0 … 1RXeHCdotsject
@typeCode
cs0 … 1FRCT
@contextControlCode
cs0 … 1FOP
 Example<recordTarget typeCode="RCT" contextControlCode="OP">
  <patientRole classCode="PAT">
    <id root="1.2.3.999" extension="__example only__"/>    <addr>
      <streetAddressLine>HSE M CASSAR STR</streetAddressLine>      <city>ISLA</city>      <country>MT</country>    </addr>
    <telecom use="HP" value="tel:+356124567891"/>    <telecom use="WP" value="mailto:elif@foo.too.mt"/>    <patient>
      <name>
        <family>BORG</family>        <given>TANIA</given>      </name>
      <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female"/>      <birthTime value="19430130"/>      <!-- Optional guardian information ; see example below-->
      <!-- Optional languageCommunication information see example below -->
    </patient>
  </patientRole>
</recordTarget>
hl7:templateId
II1 … 1RXeHCdotsject
@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.3.1.3
 IHE XD-LAB Human Patient with Non-Human Subject template
hl7:patientRole
1 … 1MXeHCdotsject
@classCode
cs0 … 1FPAT
hl7:id
II1 … *RPatient Identifiers: Primary Patient Identifier (Regional/National Health Id), Secondary Patient Identifier (Social/Insurance Number)XeHCdotsject
hl7:addr
AD.IPS1 … *RThe patient address.XeHCdotsject
 ConstraintWhen used for cross-border exchange the country address part has to be provided.
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
@nullFlavor
cs0 … 1FNI
 ConstraintSHALL NOT have mixed content except for white space
If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
 Schematron assertrolered error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
hl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address LineIPSAdotsress
 Schematron assertrolered error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MessageIf the address line is included either the city or the zip code has to be provided 
hl7:city
ADXP0 … 1CSubject's or Organization's CityIPSAdotsress
hl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal CodeIPSAdotsress
hl7:state
ADXP0 … 1CSubject's or Organization's State or ProvinceIPSAdotsress
hl7:country
ADXP0 … 1CSubject's Country.IPSAdotsress
 ConstraintThe content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
hl7:telecom
TEL1 … *RPatient’s telecom information : e.g. telephone number, e-mail address. XeHCdotsject
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@nullFlavor
cs0 … 1FNI
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
 Example<telecom use="HP" value="tel:+356124567891"/>
 Example<telecom use="WP" value="mailto:elif@foo.too.mt"/>
 Example<telecom nullFlavor="NI"/>
hl7:patient
1 … 1MXeHCdotsject
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
 Example
Japanese example (Person Name)
<patient>
  <name use="IDE">
    <family>木村</family>    <given>通男</given>  </name>
  <name use="SYL">
    <family>きむら</family>    <given>みちお</given>  </name>
  <name use="ABC">
    <family>KIMURA</family>    <given>MICHIO</given>  </name>
  <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male"/>  <birthTime nullFlavor="UNK"/></patient>
hl7:name
PN1 … *MPatient NameXeHCdotsject
 ConstraintThe Alphabetic representation of the name SHALL be always provided
hl7:family
1 … *RPatient's Family Name/SurnameXeHCdotsject
hl7:given
1 … *RPatient's Given NameXeHCdotsject
hl7:administrativeGenderCode
CE.IPS1 … 1RPatient's GenderXeHCdotsject
@nullFlavor
cs0 … 1FUNK
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 Administrative Gender (HL7 V3) (DYNAMIC)
 Example<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female">
  <translation code="2" codeSystem="2.16.840.1.113883.3.129.1.2.21" codeSystemName="Cinsiyet" displayName="Kadın"/></administrativeGenderCode>
hl7:birthTime
TS1 … 1RPatient's Date of Birth. The patient date of birth may be a partial date such as only the year.XeHCdotsject
hl7:guardian
0 … *R

The guardians of a patient.

Other patient contacts are described using the /ClinicalDocument/participant structure. The <associatedEntity> element defines the type of contact.

XeHCdotsject
@classCode
cs1 … 1FGUARD
 Example<guardian classCode="GUARD">
  <code code="AUNT" displayName="tante" codeSystem="2.16.840.1.113883.5.111"/>  <addr nullFlavor="NI"/>  <telecom use="MC" value="tel:+33-12345678"/>  <guardianPerson>
    <name>
      <family>Curie</family>      <given>Marie</given>    </name>
  </guardianPerson>
</guardian>
hl7:code
CD.IPS0 … 1RThe relationship between the patient and the guardian or other contact may be recorded in the element. XeHCdotsject
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19563 PersonalRelationshipRoleType (DYNAMIC)
hl7:addr
AD.IPS1 … *RXeHCdotsject
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
Included from 2.16.840.1.113883.10.22.11 IPS Address (DYNAMIC)
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.10637 PostalAddressUse (2005‑05‑01)
@nullFlavor
cs0 … 1FNI
 ConstraintSHALL NOT have mixed content except for white space
If there is no information, the nullFlavor attribute shall have a value of 'NI' and no address parts shall be present, otherwise there shall be no nullFlavor attribute, and at least one of the address parts listed below shall be present.
 Schematron assertrolered error 
 test@nullFlavor or hl7:* 
 MessageIf addr is not nullflavored at least one sub element has to be provided 
hl7:streetAddressLine
ADXP0 … *CSubject's or Organization's Street Address LineIPSAdotsress
 Schematron assertrolered error 
 testhl7:streetAddressLine and (hl7:city or hl7:postalCode) 
 MessageIf the address line is included either the city or the zip code has to be provided 
hl7:city
ADXP0 … 1CSubject's or Organization's CityIPSAdotsress
hl7:postalCode
ADXP0 … 1CSubject's or Organization's Postal CodeIPSAdotsress
hl7:state
ADXP0 … 1CSubject's or Organization's State or ProvinceIPSAdotsress
hl7:country
ADXP0 … 1CSubject's Country.IPSAdotsress
 ConstraintThe content of this element SHALL be selected EITHER from ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300  DYNAMIC OR MAY be selected from ISO Country Alpha-3 2.16.840.1.113883.1.11.171 DYNAMIC, IF the country is not specified in ValueSet ISO Country Alpha-2 urn:oid:2.16.840.1.113883.1.11.20300.
hl7:telecom
TEL1 … *RGuardian’s telecom information: e.g. telephone number; e-mail address. XeHCdotsject
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@nullFlavor
cs0 … 1FNI
 ConstraintIf there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
hl7:guardianPerson
1 … 1RXeHCdotsject
hl7:name
PN1 … *RPatient Guardian's NameXeHCdotsject
hl7:family
ENXP1 … *RPatient Guardian's Family Name/SurnameXeHCdotsject
hl7:given
ENXP1 … *RPatient Guardian's Given NameXeHCdotsject
hl7:languageCommunication
0 … *RXeHCdotsject
hl7:languageCode
CS1 … 1RPatient’s languageXeHCdotsject
 ConstraintThe two characters form SHALL be used when available; otherwise the three characters representation SHALL be adopted
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.19 Language Code (DYNAMIC)
 Example
British English
<languageCode code="en-GB"/>
 Example
Amurdak (Australia)
<languageCode code="amg-AU"/>
 Schematron assertrolered error 
 testmatches(@code,'[a-z]{2,3}-[A-Z]{2,3}') 
 MessageThe language code SHALL be in the form nn-CC or nnn-CCC, in accordance with BCP 47 (e.g. nn is the ISO language code; CC is ISO country code) 
Included1 … *R from 2.16.840.1.113883.2.51.10.5 XeH CDA author (DYNAMIC)

The laboratory report can be authored by a software system or by a person or by both.
The author/time element carries the date&time the laboratory report was produced.

hl7:author
1 … *RXeHCdotsthor
@typeCode
cs0 … 1FAUT
@contextControlCode
cs0 … 1FOP
 Example<author>
  <time value="201212290600+0100"/>  <assignedAuthor>
    <id root="2.16.840.1.113883.2.9.4.3.2" extension="RSSMRA00A01F205F" assigningAuthorityName="Ministero Economia e Finanze"/>    <addr use="WP">
      <streetAddressLine>Viale della Cristallina 3</streetAddressLine>      <city>Bologna</city>      <state>BO</state>      <postalCode>40121</postalCode>      <country>IT</country>    </addr>
    <telecom use="WP" value="tel:+39-051-34343434"/>    <assignedPerson>
      <name>
        <given>Paolo</given>        <family>Rossi</family>      </name>
    </assignedPerson>
  </assignedAuthor>
  <representedOrganization>
    <!-- template 'IPS CDA Organization' (dynamic) -->
  </representedOrganization>
</author>
hl7:functionCode
CE.IPS0 … 1RFunction of the author (e.g. "Physician on duty", ...). Binding of this element is left open and needs to be set according to project policies.XeHCdotsthor
hl7:time
TS.IPS.TZ1 … 1RThe author/time element represents the start time of the author’s participation in the creation of the clinical document. XeHCdotsthor
 Example<time value="201212290600+0100"/>
hl7:assignedAuthor
1 … 1RXeHCdotsthor
@classCode
cs0 … 1FASSIGNED
hl7:id
II1 … *RAuthor Identifier(s)

in case the author is a device, the UDI Device Identifier MAY be specified as a second id element.
XeHCdotsthor
@nullFlavor
cs0 … 1 
hl7:code
CE.IPS (extensible)0 … 1RA code, which identifies the profession/competence/specialty of the author when it is a person.XeHCdotsthor
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
 Example<code code="221" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO" displayName="Medical doctors"/>
hl7:addr
AD.IPS1 … *RXeHCdotsthor
 Example<addr use="WP">
  <streetAddressLine>Viale della Cristallina 3</streetAddressLine>  <city>Bologna</city>  <state>BO</state>  <postalCode>40121</postalCode>  <country>IT</country></addr>
hl7:telecom
TEL.IPS1 … *RXeHCdotsthor
@use
set_cs0 … 1 
 CONF
The value of @use shall be drawn from value set 2.16.840.1.113883.1.11.201 TelecommunicationAddressUse (DYNAMIC)
@value
st0 … 1 
 Example<telecom use="WP" value="tel:+39-051-34343434"/>
 Example<telecom nullFlavor="NI"/>
Choice1 … 1Elements to choose from:
hl7:assignedPerson
0 … 1CXeHCdotsthor
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
hl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this documentXeHCdotsthor
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
hl7:family
1 … *RXeHCdotsthor
hl7:given
1 … *RXeHCdotsthor
hl7:assignedAuthoringDevice
0 … 1CContains 2.16.840.1.113883.2.51.10.90 XeH CDA Device (DYNAMIC)XeHCdotsthor
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
hl7:representedOrganization
0 … 1RContains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)XeHCdotsthor
Included0 … 1 from 2.16.840.1.113883.2.51.10.7 XeH CDA dataEnterer (DYNAMIC)
Represents the participant who has transformed a dictated note into text.
hl7:dataEnterer
0 … 1RXeHCdotserer
hl7:time
TS.IPS.TZ1 … 1RTime of entering the data into the originating system XeHCdotserer
hl7:assignedEntity
0 … 1RRepresents the participant who has transformed a dictated note into text. A person entering the data into the originating system.XeHCdotserer
hl7:id
0 … *RUnique identification of the data entererXeHCdotserer
hl7:addr
AD.IPS1 … *RXeHCdotserer
hl7:telecom
TEL.IPS1 … *RXeHCdotserer
hl7:assignedPerson
1 … 1RXeHCdotserer
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
hl7:name
PN1 … *MName of the data entererXeHCdotserer
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
hl7:family
1 … *RFamily Name/SurnameXeHCdotserer
hl7:given
1 … *RGiven NameXeHCdotserer
hl7:representedOrganization
0 … 1ROrganization the data enterer is acting for
Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
XeHCdotserer
Included1 … 1R from 2.16.840.1.113883.2.51.10.6 XeH CDA custodian (DYNAMIC)

It represents the organization that is in charge of maintaining the laboratory report.

hl7:custodian
1 … 1RXeHCdotsdian
@typeCode
cs0 … 1FCST
 Example<custodian typeCode="CST">
  <assignedCustodian classCode="ASSIGNED">
    <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
      <!-- template 'IPS CDA Organization' (dynamic) -->
    </representedCustodianOrganization>
  </assignedCustodian>
</custodian>
hl7:assignedCustodian
1 … 1RXeHCdotsdian
@classCode
cs0 … 1FASSIGNED
hl7:representedCustodianOrganization
1 … 1RContains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)XeHCdotsdian
Included0 … * from 2.16.840.1.113883.2.51.10.14 XeH Information Recipient (DYNAMIC)

The informationRecipient/intendedRecipient element can be multiple. It introduces an intended recipient of the laboratory report, other than the Ordering Provider (described as a referrer participant).
These elements carry the list of the originally intended recipients of the laboratory report, i.e., those who were known at the time the report was created and published for sharing.

hl7:informationRecipient
0 … *XeHIdotsient
hl7:templateId
II1 … 1MXeHIdotsient
@root
uid1 … 1F2.16.840.1.113883.2.51.10.14
hl7:templateId
II1 … 1MXeHIdotsient
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.67.10.15
hl7:templateId
II0 … *RXeHIdotsient
hl7:intendedRecipient
1 … 1RXeHIdotsient
hl7:id
II0 … *RXeHIdotsient
hl7:addr
AD1 … *RXeHIdotsient
hl7:telecom
TEL1 … *RXeHIdotsient
hl7:informationRecipient
0 … 1Contains 2.16.840.1.113883.2.51.10.73 XeH CDA Person (DYNAMIC)XeHIdotsient
hl7:receivedOrganization
0 … 1Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)XeHIdotsient
Included0 … 1R from 2.16.840.1.113883.2.51.10.8 XeH CDA legalAuthenticator (DYNAMIC)

This element carries the person who has legally authenticated the report, and the organization represented by this person.
The sub-element time carries the date&time this legal authentication took place. The sub-element signatureCode carries the “signed” (S) status

If this entity happens also to be one of the validators of the laboratory results in the report, it SHALL also be documented as a validator.

hl7:legalAuthenticator
0 … 1RXeHCdotsator
 Example<legalAuthenticator>
  <time value="20111013150937-0800"/>  <signatureCode code="S"/>  <assignedEntity>
    <id extension="admin" root="2.16.17.710.780.1000.903.1.1.3.3"/>    <assignedPerson>
      <name>
        <given>John</given>        <family>Español Smith</family>      </name>
    </assignedPerson>
    <representedOrganization>
      <name>Healthcare Facility's name</name>      <addr>
        <country>NL</country>        <streetName>Duinweg</streetName>        <houseNumber>23</houseNumber>        <postalCode>7364 RX</postalCode>        <city>Amsterdam</city>      </addr>
    </representedOrganization>
  </assignedEntity>
</legalAuthenticator>
hl7:time
TS.IPS.TZ1 … 1MTime of signing the documentXeHCdotsator
hl7:signatureCode
CS1 … 1RSignature codeXeHCdotsator
@code
CONF0 … 1FS
hl7:assignedEntity
0 … 1RThe entity that is responsible for the legal authentication of the CDA documentXeHCdotsator
hl7:id
1 … *RUnique identification of legal authenticatorXeHCdotsator
hl7:code
CE.IPS (preferred)A code, which identifies the profession/competence/specialty of the author when it is a person.
XeHCdotsator
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
hl7:addr
AD.IPS1 … *RXeHCdotsator
hl7:telecom
TEL.IPS1 … *RXeHCdotsator
hl7:assignedPerson
1 … 1RContains 2.16.840.1.113883.2.51.10.73 XeH CDA Person (DYNAMIC)XeHCdotsator
hl7:representedOrganization
1 … 1MOrganization the legal authenticator is acting for
Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)
XeHCdotsator
Included1 … *R from 2.16.840.1.113883.2.51.10.44 XeH Results Validator (DYNAMIC)

When present it represents the clinical expert who performed the clinical validation (see the entries “validator” and “clinical expert” in the glossary in LAB TF-1:1.11) of the report or of a subset of its results, also called the validator.

There MAY be more than one validator of the report. All the validators SHALL appear in the report header as authenticator elements AND, in the case of multiple validators, each individual validator SHALL be associated with the particular sections of the report he or she validated. In this case, the validator of a section SHALL also appear in the entry this section is derived from.

 ConstraintA Laboratory Report SHALL contain a Result Validator IF KNOWN. A Laboratory Report with sdtc:statusCode set to "final" (or a later stage) SHALL always contain a Result Validator.
hl7:authenticator
1 … *RXeHCdotsator
@typeCode
cs1 … 1FAUTHEN
hl7:templateId
II1 … 1MXeHCdotsator
@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.3.1.5
hl7:time
TS1 … 1RXeHCdotsator
hl7:signatureCode
CS1 … 1RXeHCdotsator
hl7:assignedEntity
1 … 1RXeHCdotsator
@classCode
cs0 … 1FASSIGNED
hl7:id
II1 … *RXeHCdotsator
hl7:code
CE.IPS (preferred)0 … 1RA code, which identifies the profession/competence/specialty of the author when it is a person.
XeHCdotsator
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
hl7:addr
AD1 … *RXeHCdotsator
hl7:telecom
TEL1 … *RXeHCdotsator
 Schematron assertrolered error 
 testnot(hl7:assignedPerson) or hl7:assignedPerson/hl7:name 
 Messagethe <name/> sub-element of <assignedPerson/> SHALL be present. 
hl7:assignedPerson
0 … 1RContains 2.16.840.1.113883.2.51.10.73 XeH CDA Person (DYNAMIC)XeHCdotsator
hl7:representedOrganization
0 … 1RContains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)XeHCdotsator
Included0 … 1R from 2.16.840.1.113883.2.51.10.48 XeH Ordering Provider (DYNAMIC)

In particular, when the ordering provider of the order (or group of orders) fulfilled by this laboratory report is present in the CDA, it SHALL be documented as a participant with the attribute typeCode valued “REF” (referrer).

hl7:participant
0 … 1RReferral Ordering PhysicianXeHOdotsider
@typeCode
cs1 … 1FREF
hl7:templateId
II1 … 1XeHOdotsider
@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.3.1.6
hl7:templateId
II1 … 1XeHOdotsider
@root
uid1 … 1F2.16.840.1.113883.2.51.10.48
hl7:time
IVL_TS1 … 1RThis element represents the date and time the order was placed. Time MAY be present.XeHOdotsider
hl7:associatedEntity
1 … 1XeHOdotsider
hl7:code
CE.IPS (preferred)0 … 1A code, which identifies the profession/competence/specialty of the author when it is a person.
XeHOdotsider
 CONF
The value of @code comes preferably from value set 2.16.840.1.113883.11.22.53 IPS Healthcare Professional Roles (DYNAMIC)
hl7:addr
AD1 … *RThe address of this person (referral ordering physician) SHALL be present.XeHOdotsider
hl7:telecom
TEL1 … *RThe telecom of this person (referral ordering physician) SHALL be present.XeHOdotsider
hl7:associatedPerson
0 … 1RContains 2.16.840.1.113883.2.51.10.73 XeH CDA Person (DYNAMIC)XeHOdotsider
hl7:scopingOrganization
0 … 1Contains 2.16.840.1.113883.10.22.9.1 IPS CDA Organization (DYNAMIC)XeHOdotsider
Included0 … 1R from 2.16.840.1.113883.2.51.10.11 XeH inFulfillmentOf (DYNAMIC)

It represents the Placer Order or the Placer Group that was fulfilled, the id of which is carried by inFulfillmentOf/order/id.

hl7:inFulfillmentOf
0 … 1RXeHidotsntOf
@typeCode
cs0 … 1FFLFS
hl7:order
1 … 1RXeHidotsntOf
@classCode
cs0 … 1FACT
@moodCode
cs1 … 1FRQO
hl7:id
II1 … *RIdentifier of the order
XeHidotsntOf
hl7:code
CE0 … 1Type of orderXeHidotsntOf
hl7:priorityCode
CE0 … 1XeHidotsntOf
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
Included0 … * from 2.16.840.1.113883.2.51.10.47 XeH Lab DocumentationOf (DYNAMIC)
Reference to the ServiceEvent(s) based on which this document has been created.
hl7:documentationOf
0 … *RThere SHALL be exactly one documentationOf/serviceEvent element present for each Laboratory Specialty Section in the CDA Body of the report.

The code of the serviceEvent SHALL be exactly the same as the code of the referred Laboratory Specialty Section (see below)
XeHLdotsonOf
hl7:serviceEvent
1 … 1RXeHLdotsonOf
hl7:code
CE.IPS1 … 1RService Event codeXeHLdotsonOf
 ConstraintThis code SHALL be set to exact the same code, as the code of the Laboratory Specialty section this serviceEvent element refers to.
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.2.51.13.1.2 XeH Lab Study Types (DYNAMIC)
hl7:effectiveTime
IVL_TS0 … 1

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

XeHLdotsonOf
lab:statusCode
CS0 … 1

This Laboratory Report Content Module can express both final and non-final reports. To distinguish between the two, the statusCode element has been added to the documentationOf/serviceEvent element. A non-final report is a report documenting a serviceEvent, which is in the status "active". This sub-element serviceEvent/statusCode is optional. When it is not present the serviceEvent is assumed to be in the status "completed".

XeHLdotsonOf
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.4 ActStatusActiveCompleted (DYNAMIC)
hl7:performer
0 … *

Laboratory Performer template in the CDA header


Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC)
XeHLdotsonOf
Included0 … 2R from 2.16.840.1.113883.10.22.2.7 IPS CDA relatedDocument (DYNAMIC)

A reference to a ParentDocument representing the source of a document revision, addenda, or transformation.

 ConstraintA conformant CDA document can have:
  • a single relatedDocument with typeCode "APND"; OR
  • a single relatedDocument with typeCode "RPLC"; OR
  • a single relatedDocument with typeCode "XFRM";  OR
  • a combination of two relatedDocuments with typeCodes "XFRM" and "RPLC"; OR
  • a combination of two relatedDocuments with typeCodes "XFRM" and "APND". 
No other combinations are allowed. 
hl7:relatedDocument
0 … 2RIPSCdotsment
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.11610 x_ActRelationshipDocument (DYNAMIC)
hl7:parentDocument
1 … 1RIPSCdotsment
@classCode
cs0 … 1FDOCCLIN
@moodCode
cs0 … 1FEVN
hl7:id
II1 … *RIPSCdotsment
hl7:code
CD.IPS0 … 1RIPSCdotsment
@codeSystem
CONF0 … 1F2.16.840.1.113883.6.1
hl7:text
ED0 … 1RIPSCdotsment
hl7:setId
II0 … 1RIPSCdotsment
hl7:versionNumber
INT0 … 1RIPSCdotsment
Included0 … 1 from 2.16.840.1.113883.2.51.10.71 XeH Lab ComponentOf (DYNAMIC)

It describes the encounter during which the reported lab observations were ordered. When present the encounter :

  • is identified with an id element: encompassingEncounter/id
  • have an effective time that represents the time interval (possibly still running, e.g., an inpatient current stay) of the encounter or a point in time at which the encounter took place (e.g., an outpatient consultation): encompassingEncounter/ effectiveTime

The encounter can provide any number of encounter participants (encompassingEncounter/encounterParticipant/assignedEntity).
The encounter could precise the patient location during this encounter. This is the healthcare facility in which the patient was located when the reported lab test observations were ordered: encompassingEncounter/location/healthCareFacility. This healthcare facility can be represented as a physical place (e.g., room, floor, building, office) or as an organization (e.g., service, department, team) or both: healthCareFacility/location, healthCareFacility/serviceProviderOrganization.

hl7:componentOf
0 … 1XeHLdotsntOf
@typeCode
cs0 … 1FCOMP
hl7:templateId
II1 … 1MXeHLdotsntOf
@root
uid1 … 1F2.16.840.1.113883.2.51.10.71
hl7:encompassingEncounter
1 … 1RXeHLdotsntOf
@classCode
cs0 … 1FENC
@moodCode
cs0 … 1FEVN
hl7:id
II1 … *RIdentifier of the encounter (e.g. identifier of the hospital stay)XeHLdotsntOf
hl7:code
CE (extensible)0 … 1Code describing the kind of clinical encounter during which the documented act(s) or ServiceEvent occurred.
XeHLdotsntOf
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC)
hl7:effectiveTime
IVL_TS1 … 1RXeHLdotsntOf
hl7:low
IVXB_TS1 … 1RStart date time of the encounter (e.g. date of admission)XeHLdotsntOf
hl7:high
IVXB_TS1 … 1REnd date time of the encounter (e.g. date of discharge)
XeHLdotsntOf
hl7:responsibleParty
0 … 1
The provider (person or organization) who has primary responsibility for the encounter. The responsible provider is not necessarily present in an encounter, but is accountable for the action through the power to delegate, and the duty to review actions with the performing participant.

When the responsible party is an organization, the responsible party is reflected by the presence of a scoping Organization, without a playing entity.

Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)
XeHLdotsntOf
@typeCode
cs0 … 1FRESP
hl7:location
0 … 1
The location where the service is done. May be a static building (or room therein) or a moving location (e.g., ambulance, helicopter, aircraft, train, truck, ship, etc.)

The setting of an encounter (e.g. cardiology clinic, primary care clinic, rehabilitation hospital, skilled nursing facility) can be expressed in HealthCareFacility.code. Note that setting and physical location are not the same. 
XeHLdotsntOf
@typeCode
cs0 … 1FLOC
hl7:healthCareFacility
1 … 1RXeHLdotsntOf
@classCode
cs0 … 1FSDLOC
hl7:id
II0 … *XeHLdotsntOf
hl7:code
CE0 … 1XeHLdotsntOf
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC)
hl7:location
0 … 1Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC)XeHLdotsntOf
hl7:serviceProviderOrganization
0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)XeHLdotsntOf
hl7:component
1 … 1MXeHLdotsport
hl7:structuredBody
1 … 1RXeHLdotsport
Choice1 … *

Content Modules for CDA Sections (Level 2)

A laboratory report SHALL have a structuredBody. This body is organized as a tree of up to two levels of sections, delivering the human-readable content of the report: Top level sections represent laboratory specialties. A top level section SHALL contain either one text block carrying all the text results produced for this specialty along with a single Laboratory Data Processing Entry or a set of Laboratory Report Item Sections. In the first case the specialty section happens to also be a leaf section. In the latter case, each (second level) leaf section contained in the (top level) specialty section represents a Report Item: i.e., a battery, a specimen study (especially in microbiology), or an individual test. In addition, any leaf section SHALL contain a single Laboratory Data Processing Entry containing the observations of that section in a machine-readable format.

Elements to choose from:
hl7:component
0 … *RVariant 1: section with text and entry
Contains 2.16.840.1.113883.2.51.10.34 XeH Laboratory Specialty Section, Variant 1 (DYNAMIC)
XeHLdotsport
hl7:component
0 … *RVariant 2: section with one to many subsections "Laboratory Report Item" 
Contains 2.16.840.1.113883.2.51.10.54 XeH Laboratory Specialty Section, Variant 2 (DYNAMIC)
XeHLdotsport
hl7:component
0 … 1

Narrative expression of comments accompanying the report, such as suggestions for evaluation, technical notes from the laboratory, etc.

Examples:

Suggestion: "This result should be evaluated in relation to the patient's medical history and clinical condition."
Technical note: "A list of accredited examination(s) is available at www.laboratory.com."


Contains 2.16.840.1.113883.2.51.10.58 XeH Annotation Comment (DYNAMIC)
XeHLdotsport
hl7:component
0 … 1Reason for referral, as derived from the order if available. Should include one or more diagnoses which were the basis of the referral or the question of the laboratory assignment, e.g. suspected diagnosis.

Note: Other diagnosis, problems or conditions relevant for the laboratory examination interpretation, should be provided in section "XeH Problems"

Contains 2.16.840.1.113883.2.51.10.94 XeH Coded Reason for Referral Section (DYNAMIC)
XeHLdotsport
hl7:component
0 … 1Other diagnosis, problems or conditions, relevant for the laboratory examination interpretation, as derived from the order if available.

Contains 2.16.840.1.113883.2.51.10.23 XeH Problems Section (DYNAMIC)
XeHLdotsport
hl7:component
0 … 1Vital signs relevant for the laboratory examination interpretation, as derived from the order if available.
Contains 2.16.840.1.113883.2.51.10.82 XeH Vital Signs Section (DYNAMIC)
XeHLdotsport
hl7:component
0 … 1Pregnancy information, as derived from the order if available.

Contains 2.16.840.1.113883.10.22.3.11 IPS History of Pregnancy Section (DYNAMIC)
XeHLdotsport
hl7:component
0 … 1Optional information on sources of reimbursement of the performed laboratory tests
Contains 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7 IHE Payers section (DYNAMIC)
XeHLdotsport