ClinicalDocument/recordTarget SHALL be present and SHALL conform to the Human Patient,
Non-Human Subject or Human Patient with Non-Human Subject templates defined below.
There are 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…) 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).
Human Patient with Non-Human Subject
When the report assembles observations for a human (patient) with observations produced
using a non-human specimen, the recordTarget SHALL represent the human patient. In
accordance with the HL7 CDA R2 standard and further constrained by this specification,
the presence of name, addr and telecom is required for all entities in the
document including the human patient. Additionally, the following SHALL be present.
"1.3.6.1.4.1.19376.1.3.3.1.3"
<templateId root="1.3.6.1.4.1.19376.1.3.3.1.3"/> - The templateId element identifies
this recordTarget as a human patient directly impacted by a non-human subject of laboratory
testing. The templateId SHALL have root="1.3.6.1.4.1.19376.1.3.3.1.3".
<id/> - recordTarget/patientRole/id SHALL be present. It SHALL be representative of
the id of the human patient. In this template, the id of the non-human subject is
not provided in the header. On a special note, at present, if the document contains
a patient and a subject (as in the case of rabies, for example), documentation of
the id of the subject cannot be
accomplished without an extension to CDA.
<administrativeGenderCode/> - The patientRole/patient/administrativeGenderCode SHALL
be present.
<birthTime/> - The patientRole/patient/birthTime SHALL be present.
<structuredBody> mark-up - In addition to the elements specified in the CDA header
for the patient, the non-human subject SHALL be represented in a Subject element in
level 3 entries in the structuredBody as described in template Non-Human Subject 1.3.6.1.4.1.19376.1.3.3.1.2.1.
Context
Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.3.1.3
Classification
CDA Header Level Template
Open/Closed
Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 0 templates
Template Human Patient with Non-Human Subject
ClinicalDocument/recordTarget SHALL be present and SHALL conform to the Human Patient,
Non-Human Subject or Human Patient with Non-Human Subject templates defined below.
There are three varieties of laboratory reports:
Referto di Medicina di Laboratorio (LAB)
get)