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draft Template  Laboratory Report Data Processing Entry

Id 2.16.840.1.113883.3.1937.777.63.10.589 Effective Date 2024‑06‑18 14:13:32
Other versions this id:
Status draft Draft Version Label 2017
Name LaboratoryReportDataProcessingEntry Display Name Laboratory Report Data Processing Entry
Description
en-US One Laboratory Report Data Processing Entry SHALL be present in each leaf section of the report. The entry element SHALL be present and have its root attribute valued "1.3.6.1.4.1.19376.1.3.1". The entry SHALL contain a single act sub-element. This act is hereafter referred to as the Specimen Act. All other CDA level 3 content modules are nested in this one act. The Specimen Act shall contain at least one Laboratory Observation. If all observations of the entry have been produced on the same specimen, this specimen SHALL be attached to the top Specimen Act as a specimen sub-element.
A particular section of the laboratory report MAY carry results more confidential than the rest of the report (e.g. the section of the HIV serology). This is expressed with the confidentialityCode sub-element of the Specimen Act.
The Laboratory Report Data Processing Entry SHALL conform to statements here and those made in the following tables and sections.
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 15 templates
Uses as Name Version
1.3.6.1.4.1.19376.1.3.3.1.2.1 Containment active Non-Human Subject (2017) DYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.3.1 Containment active Human Patient with Non-Human Subject (2017) DYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.7 Containment active Laboratory Performer (2017) DYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.5 Containment active Laboratory Results Validator (2017) DYNAMIC
1.3.6.1.4.1.19376.1.3.1.1 Containment active Notification Organizer (2017) DYNAMIC
1.3.6.1.4.1.19376.1.3.1.2 Containment active Specimen Collection (2017) DYNAMIC
1.3.6.1.4.1.19376.1.3.1.3 Containment active Specimen Received (2017) DYNAMIC
1.3.6.1.4.1.19376.1.3.1.4 Containment active Laboratory Battery Organizer (2017) DYNAMIC
1.3.6.1.4.1.19376.1.3.1.5 Containment active Laboratory Isolate Organizer (2017) DYNAMIC
1.3.6.1.4.1.19376.1.3.1.6 Containment active Laboratory Observation (2017) DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.2 Containment active IHE Comment Entry (2014) DYNAMIC
1.3.6.1.4.1.19376.1.3.1.1.1 Containment active Notifiable Condition (2017) DYNAMIC
1.3.6.1.4.1.19376.1.3.1.1.2 Containment active Case Identification (2017) DYNAMIC
1.3.6.1.4.1.19376.1.3.1.1.3 Containment active Outbreak Identification (2017) DYNAMIC
1.3.6.1.4.1.19376.1.3.10.9.2 Containment active Multimedia Embedded Content (2017) DYNAMIC
Relationship Specialization: template 1.3.6.1.4.1.19376.1.3.1 Laboratory Report Data Processing Entry (2008‑08‑08)
ref
XDLAB-

Specialization: template 2.16.840.1.113883.10.12.301 CDA Act (2005‑09‑07)
ref
ad1bbr-
Example
Laboratory Report Data Processing Entry within a Specialty section
<entry typeCode="DRIV">
  <templateId root="1.3.6.1.4.1.19376.1.3.1"/>  <act classCode="ACT" moodCode="EVN">
    <!-- Specialty Level Entry : LOINC Specialty Code -->
    <code code="18719-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Chemistry Studies">
      <statusCode code="completed"/>      <effectiveTime value="200806180512"/>      <specimen typeCode="SPC">
        <specimenRole classCode="SPEC">
          <!-- .. -->
        </specimenRole>      </specimen>      <entryRelationship typeCode="COMP">
        <!-- .. -->
      </entryRelationship>      <!-- .. -->
    </code>  </act></entry>
Example
Laboratory Report Data Processing Entry within a Report Item Section
<entry typeCode="DRIV">
  <templateId root="1.3.6.1.4.1.19376.1.3.1"/>  <act classCode="ACT" moodCode="EVN">
    <!-- Report Item Level Entry : Result Item Code -->
    <code code="12814-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="POTASSIUM" originalText="Serum potassium">
      <statusCode code="completed"/>      <effectiveTime value="200806180512"/>      <specimen typeCode="SPC">
        <specimenRole classCode="SPEC">
          <!-- .. -->
        </specimenRole>      </specimen>      <entryRelationship typeCode="COMP">
        <!-- .. -->
      </entryRelationship>      <!-- .. -->
    </code>  </act></entry>
Item DT Card Conf Description Label
hl7:act
 		1 … 1

Per la codifica a Livello 3 Machine-readable delle informazioni contenute nel Referto di Medicina di Laboratorio, si osserva che per ogni section, sia section di specialità che section foglioa, tutte le informazioni del Referto di Medicina di Laboratorio, afferenti alla section, sono modellate a partire da un unico elemnto entry/act, ossia tutti gli elementi di livello 3 utilizzati per modellare le informazioni del Refererto di Medicina di Laboratorio afferenti alla section sono contenuti gerarchicamente nell'unico elemento entry/act della section

@classCode
 		cs 1 … 1 F ACT
@moodCode
 		cs 1 … 1 F EVN
hl7:code
 		CD 1 … 1 R

L'elemento definisce la tipologia delle informazioni modellate all'interno della classe act. è obbligatorio. L’elemento component/section/entry/act deve contenere l’elemento act/code che DEVE coincidere con l’elemento section/code della section a cui entry/act è associato

@code
 		cs 1 … 1 R
@codeSystem
 		uid 1 … 1 R
@codeSystemName
 		st 0 … 1  
@displayName
 		st 0 … 1  
hl7:statusCode
 		CS 1 … 1 M

L'elemento code deve assumere uno dei seguenti valori:

  • Completed: quando tutti i risultati degli esami afferenti alla section sono presenti e completi

  • Active: quando non tutti i risultati degli esami afferenti alla section sono presenti ma potrebbero esserlo in futuro

  • Aborted: quando i risultati degli esami afferenti alla section non sono completi, alcuni risultati possono essere presenti, ma non tutti i risultati sono stati completati, nè potrebbero esserlo in futuro.

  CONF
@code SHALL be "completed"
or
@code SHALL be "active"
or
@code SHALL be "aborted"
Choice 0 … 1 Elements to choose from:
hl7:subject
 		0 … 1 en-US subject in case of a non-human subject
Contains 1.3.6.1.4.1.19376.1.3.3.1.2.1 Non-Human Subject (DYNAMIC)
@typeCode
 		cs 0 … 1 F SBJ
hl7:subject
 		0 … 1 en-US subject in case of a non-human subject
Contains 1.3.6.1.4.1.19376.1.3.3.1.3.1 Human Patient with Non-Human Subject (DYNAMIC)
@typeCode
 		cs 0 … 1 F SBJ
hl7:performer
 		0 … * en-US performer participation used if different from the performer of the header, to supersede it for this section.
Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC)
@typeCode
 		cs 0 … 1 F PRF
hl7:author
 		0 … * en-US author used if different from the author of the header, to supersede it for this section.
hl7:participant
 		0 … * en-US Other participants such as validator (AUTHEN) or responsible party (RESP) or device (DEV)
  • AUTHEN: The verifier of the battery organizer. In the case where a laboratory report has multiple verifiers. Each verifier is attached to the subset of batteries/observations he or she verified, by the means of a <participant> element.

Contains 1.3.6.1.4.1.19376.1.3.3.1.5 Laboratory Results Validator (DYNAMIC)
where [@typeCode='AUTHEN']
hl7:participant
 		0 … * en-US Other participants such as validator (AUTHEN) or responsible party (RESP) or device (DEV)
  • RESP: The person responsible for the provision of the battery. In the case where this battery is subcontracted to an external laboratory, this external laboratory (with its address and telcom) and the actual performer is represented by a <performer> element, whereas the Director of this subcontractor laboratory is carried by the <participant> element being attached to the same level as the <performer> element.
where [@typeCode='RESP']
@typeCode
 		cs 1 … 1 F RESP
hl7:participant
 		0 … * en-US Other participants such as validator (AUTHEN) or responsible party (RESP) or device (DEV)
  • DEV: A device or equipment, which was used to produce this battery of results (e.g. an analyzer).
where [@typeCode='DEV']
@typeCode
 		cs 1 … 1 F DEV
hl7:entryRelationship
 		0 … * R Contains 1.3.6.1.4.1.19376.1.3.1.1 Notification Organizer (DYNAMIC)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Contains 1.3.6.1.4.1.19376.1.3.1.2 Specimen Collection (DYNAMIC)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Contains 1.3.6.1.4.1.19376.1.3.1.3 Specimen Received (DYNAMIC)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Contains 1.3.6.1.4.1.19376.1.3.1.4 Laboratory Battery Organizer (DYNAMIC)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Contains 1.3.6.1.4.1.19376.1.3.1.5 Laboratory Isolate Organizer (DYNAMIC)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Contains 1.3.6.1.4.1.19376.1.3.1.6 Laboratory Observation (DYNAMIC)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (DYNAMIC)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Contains 1.3.6.1.4.1.19376.1.3.1.1.1 Notifiable Condition (DYNAMIC)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Contains 1.3.6.1.4.1.19376.1.3.1.1.2 Case Identification (DYNAMIC)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Contains 1.3.6.1.4.1.19376.1.3.1.1.3 Outbreak Identification (DYNAMIC)
@typeCode
 		cs 1 … 1 F COMP
hl7:entryRelationship
 		0 … * R Contains 1.3.6.1.4.1.19376.1.3.10.9.2 Multimedia Embedded Content (DYNAMIC)
@typeCode
 		cs 1 … 1 F COMP
  Schematron assert role red error  
  test hl7:entryRelationship  
  Message A Laboratory Result Content SHALL be present.