hl7:ClinicalDocument
|
|
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
| |
Variable let |
Name |
languageCode |
|
| |
Value |
substring(cda:ClinicalDocument/cda:languageCode/@code,1,2) |
|
| Included |
1 … 1 |
M |
from 2.16.756.5.30.1.1.10.2.25 Realm (DYNAMIC)
|
hl7:realmCode
|
CS |
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
@code
|
CONF |
1 … 1 |
F |
CHE |
hl7:typeId
|
II |
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.1.3 |
@extension
|
st |
1 … 1 |
F |
POCD_HD000040 |
| Included |
|
|
from 2.16.756.5.30.1.1.1.1.3.9.1.10.2.1 Document Templates (DYNAMIC)
|
hl7:templateId
|
II |
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.1.1.3.9.1 |
| |
CDA-CH-LREP / Laboratory Reports V1 |
hl7:templateId
|
II |
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.1.1.4 |
| |
CDA-CH V2 |
hl7:templateId
|
II |
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
@root
|
uid |
1 … 1 |
F |
1.3.6.1.4.1.19376.1.3.3 |
| |
Sharing Laboratory Reports (XD-LAB) Content Module, IHE PaLM Technical Framework Revision
7.0 - July 5, 2016
|
| Included |
1 … 1 |
M |
from 2.16.756.5.30.1.1.10.2.23 Document Id (DYNAMIC)
|
hl7:id
|
II |
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
@extension
|
st |
0 |
NP |
NP/not present |
@root
|
uid |
1 … 1 |
R |
|
| |
Example |
Laborbefund gemäss CDA-CH-LREP V1 <id root="807563C2-5146-11D5-A672-00B0D022E945"/> |
| Included |
1 … 1 |
M |
from 2.16.756.5.30.1.1.1.1.3.9.1.10.2.2 Document Code (DYNAMIC)
|
hl7:code
|
CE |
1 … 1 |
M |
The code of the document MUST be specified. |
(CDA‑CH‑LREP‑V1) |
| |
CONF |
|
| Included |
1 … 1 |
M |
from 2.16.756.5.30.1.1.1.1.3.9.1.10.2.8 Document Title (DYNAMIC)
|
hl7:title
|
ST |
1 … 1 |
M |
The document title must follow the following text format where <human readable code>
is the local translation of the document LOINC code:
- [de]: 'Laborbefund - <human readable code>'
- [fr]: 'Rapport de laboratoire - <human readable code>'
- [it]: 'Referto di laboratorio - <human readable code>'
- [en]: 'Laboratory report - <human readable code>'
|
(CDA‑CH‑LREP‑V1) |
| |
Schematron assert |
role |
 error
|
|
| |
test |
not($languageCode='en') or starts-with(text(),'Laboratory report') |
|
| |
Message |
The English title must start with 'Laboratory report' |
|
| |
Schematron assert |
role |
error
|
|
| |
test |
not($languageCode='de') or starts-with(text(),'Laborbefund') |
|
| |
Message |
The German title must start with 'Laborbefund' |
|
| |
Schematron assert |
role |
error
|
|
| |
test |
not($languageCode='fr') or starts-with(text(),'Rapport de laboratoire') |
|
| |
Message |
The French title must start with 'Rapport de laboratoire' |
|
| |
Schematron assert |
role |
error
|
|
| |
test |
not($languageCode='it') or starts-with(text(),'Rapporto di laboratorio') |
|
| |
Message |
The Italian title must start with 'Rapporto di laboratorio' |
|
hl7:effectiveTime
|
TS.CH.TZ |
1 … 1 |
M |
ClinicalDocument/effectiveTime MUST exist. It contains the creation date and time
of the laboratory report. If this document replaces a previous version (linked via
parentDocument), this is the date and time of the new version.
|
(CDA‑CH‑LREP‑V1) |
| Included |
1 … 1 |
M |
from 2.16.756.5.30.1.1.10.2.19 Confidentiality Code (DYNAMIC)
|
hl7:confidentialityCode
|
CE CNE |
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
| |
CONF |
|
| Included |
1 … 1 |
M |
from 2.16.756.5.30.1.1.10.2.22 Document language (DYNAMIC)
|
hl7:languageCode
|
CS |
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
| |
CONF |
|
| Included |
1 … 1 |
M |
from 2.16.756.5.30.1.1.10.2.20 Set Id and Version Number (DYNAMIC)
|
hl7:setId
|
II |
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
@extension
|
st |
0 |
NP |
NP/not present |
@root
|
uid |
1 … 1 |
R |
|
| |
Example |
Laborbefund gemäss CDA-CH-LREP V1 <setId root="807563C2-5146-11D5-A672-00B0D022E945"/> |
hl7:versionNumber
|
INT.NONNEG |
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
| |
Example |
<versionNumber value="1"/> |
| Choice |
1 … 1 |
|
recordTarget MUST be present in one of the following characteristics:
- Human Patient: The laboratory report contain test results from samples taken exclusively
from a human patient.
- Non-Human Subject: The laboratory report contains test results from samples taken
from a non-human material (e.g., water, milk, etc.) or a living being (e.g., animal),
but not related to a human patient.
- Human Patient with Non-Human Subject: The laboratory report contains test results
from samples taken from a non-human material that is related to a human patient (e.g.,
food eaten by the patient or animal that has bitten the patient).
|
| Included |
0 … 1 |
|
from 2.16.756.5.30.1.1.1.1.3.9.1.10.2.4 Patient (recordTarget) (DYNAMIC)
Human Patient: The laboratory results contain test results from samples taken exclusively
from a human patient.
All persons (including patients) and organizations, MUST according to XD-LAB contain
name, addr and telecom.
|
hl7:recordTarget
|
|
0 … 1 |
R |
Patient (Human Patient). |
(CDA‑CH‑LREP‑V1) |
hl7:patientRole
|
|
1 … 1 |
R |
Exactly one patient MUST be declared. |
(CDA‑CH‑LREP‑V1) |
hl7:id
|
II |
1 … * |
R |
At least one patient identification MUST be declared. |
(CDA‑CH‑LREP‑V1) |
@extension
|
st |
1 … 1 |
R |
MUST contain the patient number itself. The number MUST be unique within the system
that has issued the number.
|
@root
|
uid |
1 … 1 |
R |
MUST contain the OID of the system that issued the ID. OIDs of code systems, which
are published in the public OID registry for the Swiss health care system (oid.refdata.ch)
are REQUIRED. Others are NOT ALLOWED.
|
hl7:addr
|
AD |
1 … * |
R |
All persons (including patients) and organizations, MUST according to XD-LAB contain
name, addr and telecom.
|
(CDA‑CH‑LREP‑V1) |
hl7:telecom
|
TEL |
1 … * |
R |
All persons (including patients) and organizations, MUST according to XD-LAB contain
name, addr and telecom.
|
(CDA‑CH‑LREP‑V1) |
hl7:patient
|
|
1 … 1 |
R |
Exactly one patient MUST be declared. |
(CDA‑CH‑LREP‑V1) |
hl7:name
|
PN |
1 … * |
R |
All persons (including patients) and organizations, MUST according to XD-LAB contain
name, addr and telecom.
|
(CDA‑CH‑LREP‑V1) |
hl7:administrativeGenderCode
|
CE |
1 … 1 |
R |
The sex of the patient MUST be indicated according to XD-LAB. |
(CDA‑CH‑LREP‑V1) |
| |
CONF |
|
hl7:birthTime
|
TS |
1 … 1 |
R |
The date of birth of the patient MUST be given according to XD-LAB. |
(CDA‑CH‑LREP‑V1) |
| Included |
0 … 1 |
|
from 2.16.756.5.30.1.1.10.2.26 Non-Human Subject (recordTarget) (DYNAMIC)
Non-Human Subject: The laboratory report contains test results from samples taken
from a non-human material (e.g., water, milk, etc.) or a living being (e.g., animal),
but not related to a human patient.
|
hl7:recordTarget
|
|
0 … 1 |
R |
Non-Human Subject. |
(CDA‑CH‑LREP‑V1) |
hl7:templateId
|
II |
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
@root
|
uid |
1 … 1 |
F |
1.3.6.1.4.1.19376.1.3.3.1.2 |
| |
Schematron assert |
role |
error
|
|
| |
test |
//hl7:templateId[@root='1.3.6.1.4.1.19376.1.3.3.1.2.1'] |
|
| |
Message |
In addition to the elements specified in the CDA header for the non-human subject,
this non-human subject SHALL be represented in a Subject element in level 3 entries
in the structuredBody. |
|
hl7:patientRole
|
|
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
@classCode
|
cs |
0 … 1 |
F |
PAT |
hl7:id
|
II |
1 … * |
R |
|
(CDA‑CH‑LREP‑V1) |
@extension
|
st |
1 … 1 |
R |
MUST contain the actual number of non-human material. The number MUST be unique within
the system that issued the number.
|
@root
|
uid |
1 … 1 |
R |
MUST contain the OID of the system that issued the number. OIDs of code systems, which
are published in the public OID registry for the Swiss health care system (oid.refdata.ch)
are REQUIRED. Others are NOT ALLOWED.
|
hl7:patient
|
|
1 … 1 |
|
|
(CDA‑CH‑LREP‑V1) |
@classCode
|
cs |
0 … 1 |
F |
PSN |
@determinerCode
|
cs |
0 … 1 |
F |
INSTANCE |
@nullFlavor
|
cs |
1 … 1 |
F |
OTH |
| |
Indicates that there are laboratory tests for this non-human material in the CDA Body. |
| Included |
0 … 1 |
|
from 2.16.756.5.30.1.1.10.2.27 Human Patient with Non-Human Subject (recordTarget) (DYNAMIC)
Human Patient with Non-Human Subject: The laboratory report contains test results
from samples taken from a non-human material that is related to a human patient (e.g.,
food eaten by the patient or animal that has bitten the patient).
|
hl7:recordTarget
|
|
0 … 1 |
R |
Human Patient with Non-Human Subject. |
(CDA‑CH‑LREP‑V1) |
hl7:templateId
|
II |
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
@root
|
uid |
1 … 1 |
F |
1.3.6.1.4.1.19376.1.3.3.1.3 |
| |
Schematron assert |
role |
error
|
|
| |
test |
//hl7:templateId[@root='1.3.6.1.4.1.19376.1.3.3.1.3.1'] |
|
| |
Message |
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. |
|
hl7:patientRole
|
|
1 … 1 |
R |
Exactly one patient MUST be declared. |
(CDA‑CH‑LREP‑V1) |
hl7:id
|
II |
1 … * |
R |
At least one patient identification MUST be declared.
Note:
The identification of the non-human material MUST NOT be deklared here.
This can not be specified within the same document. See also: IHE PaLM TF3, section
6.3.2.11.3.
If the identification of the non-human material is important (for example in rabies),
two separate documents should be created (one with the human patient and one with
the non-human material).
|
(CDA‑CH‑LREP‑V1) |
@extension
|
st |
1 … 1 |
R |
MUST contain the actual number of non-human material. The number MUST be unique within
the system that issued the number.
|
@root
|
uid |
1 … 1 |
R |
MUST contain the OID of the system that issued the number. OIDs of code systems, which
are published in the public OID registry for the Swiss health care system (oid.refdata.ch)
are REQUIRED. Others are NOT ALLOWED.
|
hl7:addr
|
AD |
1 … * |
R |
All persons (including patients) and organizations, MUST contain according to XD-LAB
name, addr and telecom.
|
(CDA‑CH‑LREP‑V1) |
hl7:telecom
|
TEL |
1 … * |
R |
All persons (including patients) and organizations, MUST contain according to XD-LAB
name, addr and telecom.
|
(CDA‑CH‑LREP‑V1) |
hl7:patient
|
|
1 … 1 |
R |
Exactly one patient MUST be declared. |
(CDA‑CH‑LREP‑V1) |
hl7:name
|
PN |
1 … * |
R |
All persons (including patients) and organizations, MUST contain according to XD-LAB
name, addr and telecom.
|
(CDA‑CH‑LREP‑V1) |
hl7:administrativeGenderCode
|
CE |
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
| |
CONF |
|
hl7:birthTime
|
TS |
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
| Included |
1 … * |
M |
from 2.16.756.5.30.1.1.1.1.3.9.1.10.2.5 Author (DYNAMIC)
|
hl7:author
|
|
1 … * |
M |
At least one author MUST be declared. |
(CDA‑CH‑LREP‑V1) |
hl7:functionCode
|
CE |
0 … 1 |
C |
At least one of the listed authors must be a laboratory specialist. |
(CDA‑CH‑LREP‑V1) |
@displayName
|
st |
1 … 1 |
F |
Medical and pathology laboratory technicians |
@codeSystemName
|
st |
1 … 1 |
F |
ISCO-08 |
@codeSystem
|
oid |
1 … 1 |
F |
2.16.840.1.113883.2.9.6.2.7 |
@code
|
cs |
1 … 1 |
F |
3212 |
hl7:time
|
TS.CH.TZ |
1 … 1 |
R |
Date and time of the laboratory report creation. |
(CDA‑CH‑LREP‑V1) |
hl7:assignedAuthor
|
|
1 … 1 |
R |
The author CAN be a person or a software module. |
(CDA‑CH‑LREP‑V1) |
| |
Schematron assert |
role |
error
|
|
| |
test |
not(assignedAuthoringDevice/softwareName) or (representedOrganization) |
|
| |
Message |
For device authors the element representedOrganization is required. |
|
| |
Schematron assert |
role |
error
|
|
| |
test |
(telecom[@use='PUB' and starts-with(@value,'tel:+']) and (telecom[@use='PUB' and starts-with(@value,'mailto:']) |
|
| |
Message |
A public telephone number in the international format and a public eMail address are
required. |
|
| |
Schematron assert |
role |
error
|
|
| |
test |
(addr[@use='PUB']) |
|
| |
Message |
A public address is required. |
|
hl7:id
|
II |
1 … * |
R |
The specification of GS1 GLN is required. If it is not (yet) known, this must be declared
using nullFlavor.
For persons whose personal GLN must be specified.
For software modules the GLN of the laboratory MUST be specified.
|
(CDA‑CH‑LREP‑V1) |
@nullFlavor
|
cs |
0 … 1 |
F |
NAV |
| |
Temporarily unknown, will be filled later. |
@extension
|
st |
0 … 1 |
|
The GS1 GLN. |
@root
|
cs |
0 … 1 |
F |
2.51.1.3 |
| |
OID for GS1 GLN. |
| |
Schematron assert |
role |
error
|
|
| |
test |
(@root='2.51.1.3' and @extension) or (@nullFlavor='NAV') |
|
| |
Message |
Either the GS1 GLN or nullFlavor='NAV' is required |
|
hl7:addr
|
AD |
1 … * |
R |
Address of the laboratory. |
(CDA‑CH‑LREP‑V1) |
hl7:telecom
|
TEL |
1 … * |
R |
Means of communication of the laboratory (phone, eMail, ...). |
(CDA‑CH‑LREP‑V1) |
| Choice |
0 … 1 |
|
Elements to choose from:
|
hl7:assignedPerson
|
|
|
|
All persons and organizations, MUST according to XD-LAB contain name, addr and telecom.
Contains 2.16.756.5.30.1.1.10.9.18 Person with Name (DYNAMIC)
|
(CDA‑CH‑LREP‑V1) |
hl7:assignedAuthoringDevice
|
|
|
|
The name of the software module MUST be specified if the author is a software module.
Contains 2.16.756.5.30.1.1.1.1.3.9.1.10.9.2 Device for LIS (DYNAMIC)
|
(CDA‑CH‑LREP‑V1) |
hl7:representedOrganization
|
|
0 … 1 |
|
All persons and organizations, MUST according to XD-LAB contain name, addr and telecom.
Contains 2.16.756.5.30.1.1.10.9.19 Organization with Name, Addr, Telecom (DYNAMIC)
|
(CDA‑CH‑LREP‑V1) |
| Included |
0 … 1 |
|
from 2.16.756.5.30.1.1.10.2.7 Data Enterer (DYNAMIC)
|
hl7:dataEnterer
|
|
0 … 1 |
|
|
(CDA‑CH‑LREP‑V1) |
@typeCode
|
cs |
0 … 1 |
F |
ENT |
@contextControlCode
|
cs |
0 … 1 |
F |
OP |
hl7:time
|
TS |
0 … 1 |
|
|
(CDA‑CH‑LREP‑V1) |
hl7:assignedEntity
|
|
1 … 1 |
R |
Contains 2.16.756.5.30.1.1.10.9.12 CDA AssignedEntity (DYNAMIC)
|
(CDA‑CH‑LREP‑V1) |
| Included |
1 … 1 |
M |
from 2.16.756.5.30.1.1.1.1.3.9.1.10.2.6 Custodian (DYNAMIC)
|
hl7:custodian
|
|
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
hl7:assignedCustodian
|
|
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
hl7:representedCustodianOrganization
|
|
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
| |
Schematron assert |
role |
error
|
|
| |
test |
(telecom[@use='PUB' and starts-with(@value,'tel:+']) and (telecom[@use='PUB' and starts-with(@value,'mailto:']) |
|
| |
Message |
A public telephone number in the international format and a public eMail address are
required. |
|
| |
Schematron assert |
role |
error
|
|
| |
test |
(addr[@use='PUB']) |
|
| |
Message |
A public address is required. |
|
hl7:id
|
II |
1 … * |
R |
The specification of GS1 GLN is required. If it is not (yet) known, this must be declared
using nullFlavor.
|
(CDA‑CH‑LREP‑V1) |
@nullFlavor
|
cs |
0 … 1 |
F |
NAV |
| |
Temporarily unknown, will be filled later. |
@extension
|
st |
0 … 1 |
|
The GS1 GLN of the laboratory or the doctor's office (in the case of individual practices,
the doctor's GLN).
|
@root
|
cs |
0 … 1 |
F |
2.51.1.3 |
| |
OID for GS1 GLN |
| |
Schematron assert |
role |
error
|
|
| |
test |
(@root='2.51.1.3' and @extension) or (@nullFlavor='NAV') |
|
| |
Message |
Either the GS1 GLN or nullFlavor='NAV' is required. |
|
hl7:id
|
II |
0 … * |
C |
SASIS number (ge:ZSR / fr:RCC), if the lab services are to be refunded by the insurance. |
(CDA‑CH‑LREP‑V1) |
@extension
|
st |
1 … 1 |
R |
SASIS number (ge:ZSR / fr:RCC) of the laboratory or the physician. |
@root
|
cs |
1 … 1 |
F |
2.16.756.5.30.1.123.100.2.1.1 |
| |
OID for SASIS number (ge:ZSR / fr:RCC). |
hl7:name
|
ON |
1 … 1 |
R |
Name of the laboratory. |
(CDA‑CH‑LREP‑V1) |
hl7:telecom
|
TEL |
1 … 1 |
R |
Means of communication of the laboratory (phone., eMail, ...). |
(CDA‑CH‑LREP‑V1) |
hl7:addr
|
AD |
1 … 1 |
R |
Address of the laboratory. |
(CDA‑CH‑LREP‑V1) |
| Included |
1 … * |
M |
from 2.16.756.5.30.1.1.1.1.3.9.1.10.2.3 Recipient (DYNAMIC)
|
hl7:informationRecipient
|
|
1 … * |
M |
The laboratory report MUST contain at least one receiver. |
(CDA‑CH‑LREP‑V1) |
@typeCode
|
cs |
1 … 1 |
R |
The main recipient of the document MUST be specified using typeCode 'PRCP' (primary
recipient). Other receivers (copy to; Cc) MUST be specified using typeCode 'TRC' (tracker).
|
| |
CONF |
|
hl7:templateId
|
II |
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.1.1.3.9.1.10.2.3 |
hl7:templateId
|
II |
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
@root
|
uid |
1 … 1 |
F |
1.3.6.1.4.1.19376.1.3.3.1.4 |
hl7:intendedRecipient
|
|
1 … 1 |
M |
The laboratory report MUST contain at least one receiver. |
(CDA‑CH‑LREP‑V1) |
hl7:addr
|
AD |
1 … * |
R |
An address MUST be present according to XD-LAB. |
(CDA‑CH‑LREP‑V1) |
hl7:telecom
|
TEL |
1 … * |
R |
A communication mean MUST be present according to XD-LAB. |
(CDA‑CH‑LREP‑V1) |
hl7:informationRecipient
|
|
1 … 1 |
M |
The laboratory report MUST contain at least one receiver. The name MUST be present
according to XD-LAB.
Contains 2.16.756.5.30.1.1.10.9.18 Person with Name (DYNAMIC)
|
(CDA‑CH‑LREP‑V1) |
|
|
|
hl7:receivedOrganization
|
|
0 … 1 |
|
If the organization of the recipient is used, it MUST according to XD-LAB declare
name, addr and telecom.
Contains 2.16.756.5.30.1.1.10.9.19 Organization with Name, Addr, Telecom (DYNAMIC)
|
(CDA‑CH‑LREP‑V1) |
| Included |
0 … 1 |
|
from 2.16.756.5.30.1.1.1.1.3.9.1.10.2.7 Legal Authenticator (DYNAMIC)
|
hl7:legalAuthenticator
|
|
0 … 1 |
|
Legal authenticator. |
(CDA‑CH‑LREP‑V1) |
hl7:time
|
TS.CH.TZ |
1 … 1 |
R |
Date of the signature. |
(CDA‑CH‑LREP‑V1) |
hl7:signatureCode
|
CS |
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
@code
|
CONF |
1 … 1 |
F |
S |
@codeSystem
|
1 … 1 |
F |
2.16.840.1.113883.5.89 (Participation Signature) |
@displayName
|
1 … 1 |
F |
signed |
@codeSystemName
|
1 … 1 |
F |
ParticipationSignature |
hl7:assignedEntity
|
|
1 … 1 |
R |
The GLN MUST be used to identify the legal authenticator (e.g., laboratory manager
or responsible physician).
All persons and organizations, MUST according to XD-LAB contain name, addr and telecom.
Contains 2.16.756.5.30.1.1.1.1.3.9.1.10.9.1 AssignedEntity for Laboratory (DYNAMIC)
|
(CDA‑CH‑LREP‑V1) |
hl7:authenticator
|
|
0 … * |
|
Contains 2.16.756.5.30.1.1.10.4.8 Laboratory Results Validator (Body) (DYNAMIC)
|
(CDA‑CH‑LREP‑V1) |
 |
where [hl7:templateId [@root='2.16.756.5.30.1.1.10.4.8']] [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.3.1.5']] |
|
|
| Included |
0 … 1 |
R |
from 2.16.756.5.30.1.1.10.2.16 Order reference (DYNAMIC)
|
hl7:inFulfillmentOf
|
|
0 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
hl7:order
|
|
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
hl7:id
|
II |
1 … * |
R |
|
(CDA‑CH‑LREP‑V1) |
@extension
|
st |
1 … 1 |
R |
|
@root
|
uid |
1 … 1 |
R |
|
| Included |
0 … * |
|
from 2.16.756.5.30.1.1.10.2.28 Laboratory Performer (documentationOf) (DYNAMIC)
|
hl7:documentationOf
|
|
0 … * |
|
|
(CDA‑CH‑LREP‑V1) |
hl7:serviceEvent
|
|
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
hl7:effectiveTime
|
IVL_TS.CH.TZ |
0 … 1 |
|
Use of sub element documentationOf/serviceEvent/effectiveTime to document the time
boundaries of events in the document is appropriate.
|
(CDA‑CH‑LREP‑V1) |
hl7:performer
|
|
0 … * |
|
Laboratory Performer template in the CDA header
Contains 2.16.756.5.30.1.1.10.4.7 Laboratory Performer (Body) (DYNAMIC)
|
(CDA‑CH‑LREP‑V1) |
|
|
|
where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.3.1.7']] |
|
|
| Included |
0 … * |
|
from 2.16.756.5.30.1.1.10.2.14 Insurance Card (DYNAMIC)
|
hl7:participant
|
|
0 … * |
|
|
(CDA‑CH‑LREP‑V1) |
|
where [@typeCode='HLD'] |
|
|
@typeCode
|
cs |
1 … 1 |
F |
HLD |
@contextControlCode
|
cs |
0 … 1 |
F |
OP |
hl7:templateId
|
II |
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.127.10.2.14 |
hl7:time
|
IVL_TS |
0 … 1 |
|
|
(CDA‑CH‑LREP‑V1) |
hl7:low
|
TS |
1 … 1 |
|
|
(CDA‑CH‑LREP‑V1) |
@nullFlavor
|
cs |
1 … 1 |
F |
NASK |
hl7:high
|
TS |
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
hl7:associatedEntity
|
|
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
@classCode
|
cs |
1 … 1 |
F |
POLHOLD |
hl7:id
|
II |
0 … * |
|
|
(CDA‑CH‑LREP‑V1) |
hl7:associatedPerson
|
|
1 … 1 |
|
|
(CDA‑CH‑LREP‑V1) |
| Included |
|
|
from 2.16.756.5.30.1.1.10.9.10 CDA Person (DYNAMIC)
|
@classCode
|
cs |
0 … 1 |
F |
PSN |
@determinerCode
|
cs |
0 … 1 |
F |
INSTANCE |
hl7:name
|
PN |
1 … * |
R |
|
(CDA‑CH‑LREP‑V1) |
hl7:scopingOrganization
|
|
0 … 1 |
|
|
(CDA‑CH‑LREP‑V1) |
| Included |
|
|
from 2.16.756.5.30.1.1.10.9.11 CDA Organization (DYNAMIC)
|
@classCode
|
cs |
0 … 1 |
F |
ORG |
@determinerCode
|
cs |
0 … 1 |
F |
INSTANCE |
hl7:id
|
II |
0 … * |
|
|
(CDA‑CH‑LREP‑V1) |
hl7:name
|
ON |
1 … 1 |
|
|
(CDA‑CH‑LREP‑V1) |
hl7:telecom
|
TEL |
0 … * |
|
|
(CDA‑CH‑LREP‑V1) |
hl7:addr
|
AD |
0 … 1 |
|
|
(CDA‑CH‑LREP‑V1) |
| Included |
0 … * |
|
from 2.16.756.5.30.1.1.10.2.15 Insurance (DYNAMIC)
|
hl7:participant
|
|
0 … * |
|
|
(CDA‑CH‑LREP‑V1) |
|
where [@typeCode='COV'] |
|
|
@typeCode
|
cs |
1 … 1 |
F |
COV |
@contextControlCode
|
cs |
0 … 1 |
F |
OP |
hl7:templateId
|
II |
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.127.10.2.15 |
hl7:time
|
IVL_TS |
0 … 1 |
|
|
(CDA‑CH‑LREP‑V1) |
hl7:low
|
TS |
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
hl7:high
|
TS |
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
hl7:associatedEntity
|
|
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
@classCode
|
cs |
1 … 1 |
F |
PAYOR |
hl7:id
|
II |
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
@root
|
uid |
1 … 1 |
F |
2.51.1.3 |
hl7:associatedPerson
|
|
1 … 1 |
|
|
(CDA‑CH‑LREP‑V1) |
| Included |
|
|
from 2.16.756.5.30.1.1.10.9.10 CDA Person (DYNAMIC)
|
@classCode
|
cs |
0 … 1 |
F |
PSN |
@determinerCode
|
cs |
0 … 1 |
F |
INSTANCE |
hl7:name
|
PN |
1 … * |
R |
|
(CDA‑CH‑LREP‑V1) |
hl7:scopingOrganization
|
|
0 … 1 |
|
|
(CDA‑CH‑LREP‑V1) |
| Included |
|
|
from 2.16.756.5.30.1.1.10.9.11 CDA Organization (DYNAMIC)
|
@classCode
|
cs |
0 … 1 |
F |
ORG |
@determinerCode
|
cs |
0 … 1 |
F |
INSTANCE |
hl7:id
|
II |
0 … * |
|
|
(CDA‑CH‑LREP‑V1) |
hl7:name
|
ON |
1 … 1 |
|
|
(CDA‑CH‑LREP‑V1) |
hl7:telecom
|
TEL |
0 … * |
|
|
(CDA‑CH‑LREP‑V1) |
hl7:addr
|
AD |
0 … 1 |
|
|
(CDA‑CH‑LREP‑V1) |
| Included |
0 … * |
|
from 2.16.756.5.30.1.1.10.2.13 Document Replacement (DYNAMIC)
|
hl7:relatedDocument
|
|
0 … * |
|
|
(CDA‑CH‑LREP‑V1) |
@typeCode
|
cs |
1 … 1 |
F |
RPLC |
| |
|
hl7:parentDocument
|
|
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
hl7:id
|
II |
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
@extension
|
st |
1 … 1 |
R |
|
@root
|
uid |
1 … 1 |
R |
|
hl7:setId
|
II |
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
@extension
|
st |
1 … 1 |
R |
|
@root
|
uid |
1 … 1 |
R |
|
| |
Schematron assert |
role |
error
|
|
| |
test |
(@root=/ClinicalDocument/id/@root) and (@extension=/ClinicalDocument/id/@extension) |
|
| |
Message |
ClinicalDocument/setId: MUST be identical to the one of the replaced document |
|
hl7:versionNumber
|
INT |
1 … 1 |
M |
|
(CDA‑CH‑LREP‑V1) |
| |
Schematron assert |
role |
error
|
|
| |
test |
@value > /ClinicalDocument/versionNumber/@value |
|
| |
Message |
ClinicalDocument/versionNumber: MUST be higher than the one of the replaced document |
|
hl7:component
|
|
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
hl7:structuredBody
|
|
1 … 1 |
R |
|
(CDA‑CH‑LREP‑V1) |
hl7:component
|
|
1 … * |
M |
Main section for laboratory reports
A laboratory report MUST contain at least one main chapter in the structured body
element, which MAY contain one or more sub-chapters. No further nesting is allowed.
Each main section (Laboratory Specialty Section) contains laboratory tests of a particular
discipline (e.g., microbiology or serology) and MUST contain either text and entry
elements or sub-chapter (Laboratory Report Item Section).
In the first case, the human-readable text in the text element MUST be generated automatically
from the entry and its sub-elements, and sub-chapters ARE NOT ALLOWED.
In the second case, all subsections (Laboratory Report Item Sections) must contain
the examination results.
Contains 2.16.756.5.30.1.1.10.3.3 Laboratory Speciality Section (DYNAMIC)
|
(CDA‑CH‑LREP‑V1) |
|
|
|
where [hl7:section [hl7:templateId [@root='2.16.756.5.30.1.1.10.3.3']] [hl7:templateId
[@root='1.3.6.1.4.1.19376.1.3.3.2.1']]] |
|
|
hl7:component
|
|
0 … 1 |
|
Main section for vital signs
A laboratory report MAY include a main section in the structuredBody element that
contains vital signs of the patient (e.g., body temperature, body height and weight),
if this is of particular interest to the interpretation of the laboratory results.
Note:
This section was imported "as is" from ART-DECOR (project CDA-CH) and is currently
not further specified.
Contains 2.16.756.5.30.1.1.10.3.4 Coded Vital Signs Section (DYNAMIC)
|
(CDA‑CH‑LREP‑V1) |
|
|
|
where [hl7:section [hl7:templateId [@root='2.16.840.1.113883.10.20.1.16']] [hl7:templateId
[@root='1.3.6.1.4.1.19376.1.5.3.1.3.25']] [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2']]] |
|
|
hl7:component
|
|
0 … 1 |
|
Main section for coded results
A laboratory report MAY include a main section in the structuredBody element that
contains coded results of the patient (e.g., gestational age), if this is of particular
interest to the interpretation of the laboratory results.
Note:
This section was imported "as is" from ART-DECOR (project CDA-CH-VACD) and is currently
not further specified.
Contains 2.16.756.5.30.1.127.10.3.5 Coded Results (DYNAMIC)
|
(CDA‑CH‑LREP‑V1) |
|
|
|
where [hl7:section [hl7:templateId [@root='2.16.756.5.30.1.127.10.3.5']] [hl7:templateId
[@root='1.3.6.1.4.1.19376.1.5.3.1.3.27']] [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.28']]] |
|
|
Template Laboratory Report V1
Draft