Every Laboratory Report SHALL contain at least one Laboratory Specialty Section. Each
top section represents a specialty. A laboratory report MAY be composed of test results
from a single specialty (e.g. a microbiology report, a virology report), or from any
number of specialties (a report from a multidisciplinary laboratory).
The structure of the report allows both kinds of reports. The Laboratory Specialty Sections use the LOINC codes defined as report subject identifier
codes. A laboratory report SHALL contain one or more of these sections, in any order.
Laboratory Specialty Sections SHALL NOT be nested.
<templateId root="1.3.6.1.4.1.19376.1.3.3.2.1"/> - The templateId element identifies
this section as a Laboratory Specialty Section. The templateId SHALL be present with
root="1.3.6.1.4.1.19376.1.3.3.2.1".
<code code=" " codeSystem=" " codeSystemName=" " displayName=" "/> - The Laboratory
Specialty Section SHALL identify the LOINC laboratory specialty. The code, codeSystem,
and displayName attributes SHALL be present. The codeSystemName MAY also be present.
<title/> - The Laboratory Specialty Section <title> MAY be present. It is the local
translation of the code@displayName.
The semantic content of each specialty section is not constant between countries.
The relationship between Report Items and Specialties varies from country to country,
and MAY even vary in the same country, from a healthcare organization to another.
A Report Item can be a battery (or test panel), an individual test, or the complete
study of a specimen (particularly in the
MICROBIOLOGY STUDIES specialty). Realm extensions of this profile MAY further constrain
these definitions. 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. See 2.3.4.2.
Choice 2: Text and Entry - With this option, the Laboratory Specialty Section text
SHALL be present and not blank. This narrative block SHALL present to the human reader,
all the observations produced for this Specialty, using the various structures available
in the CDA Narrative Block schema (NarrativeBlock.xsd): tables, lists, paragraphs,
hyperlinks, footnotes, references
to attached or embedded multimedia objects. The narrative block is fully derived from
the entry containing the machine-readable result data. Additionally, a single Laboratory
Report Data Processing Entry SHALL be present with attribute typeCode="DRIV". This
entry contains the machine-readable result data from which the narrative block of
this section is derived.
Should a Laboratory Report contain multiple Laboratory Speciality Sections they need
not adhere to the same choice of representation, that is, one MAY expect a mixture
of choice 1 and choice 2 representations among multiple Laboratory Speciality Sections.
Label
sectionSpecLAB
Classification
CDA Section Level Template
Open/Closed
Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 2 templates
Il body è organizzato secondo una gerarchia di section in cui è presente il contenuto
human-readable del documento. la gerarchia di section può al più essere organizzata
su due livelli:
Section di specialità
Section Foglia
Il Referto di Medicina di Laboratorio deve contenere almeno una structuredBody/component/section
di specialità. La section di specialità può essere istanziata più volte quando ad
esempio nel referto sono presenti esami afferenti a diverse specialità, in questo
caso si potranno trovare diverse section di specialità, una per ciascuna specialità
gestita nel referto del
laboratorio.
Il blocco narrattivo è obbligatorio se la section di specialità non contiene una section
foglia.
sectcLAB
hl7:entry
0 … 1
Se structuredBody/component/section contiene almeno un elemento component/section
(la section di specialità contiene almeno una (section foglia) allora structuredBody/component/section
non deve contenere l’elemento section/entry
Se structuredBody/component/section non contiene nessun elemento component/section
allora structuredBody/component/section deve contenere uno ed un solo elemento entry.