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pending Template  General Laboratory Report

Id 2.16.756.5.30.1.1.10.1.10 Effective Date 2018‑04‑19
Status pending Under pre-publication review Version Label 2018
Name CDA-CH-LREP-GR-V1 Display Name General Laboratory Report
Description

Swiss Laboratory Report - General Report

Context Pathname /
Classification CDA Document Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 29 templates
Used by as Name Version
cdachlrep-transaction-2 Transaction pending CDA-CH-LREP - General Laboratory Report (2018) 2018‑03‑06 18:38:46
Uses as Name Version
2.16.756.5.30.1.1.10.2.25 Include active Document Realm (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.18 Include active Document Template Ids CDA-CH v2.0 - structuredBody (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.55 Include pending Document Template Ids CDA-CH-LREP V1 (2018) DYNAMIC
2.16.756.5.30.1.1.10.2.23 Include active Document Id (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.56 Include pending Document Code (2018) DYNAMIC
2.16.756.5.30.1.1.10.2.62 Include pending Document Title (2018) DYNAMIC
2.16.756.5.30.1.1.10.2.19 Include active Document Confidentiality Code (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.22 Include active Document Language (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.20 Include active Document Set Id and Version Number (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.58 Include pending Human Patient - recordTarget (2018) DYNAMIC
2.16.756.5.30.1.1.10.2.26 Include pending Non-Human Subject - recordTarget (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.27 Include pending Human Patient with Non-Human Subject - recordTarget (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.59 Include pending Author (2018) DYNAMIC
2.16.756.5.30.1.1.10.2.7 Include active Data Enterer (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.60 Include pending Custodian (2018) DYNAMIC
2.16.756.5.30.1.1.10.2.57 Include pending Recipient (2018) DYNAMIC
2.16.756.5.30.1.1.10.2.61 Include pending Legal Authenticator (2018) DYNAMIC
2.16.756.5.30.1.1.10.4.8 Containment pending Laboratory Results Validator - authenticator/participant Containment (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.16 Include active Order Reference - inFulfillmentOf (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.46 Include active Health Service - documentationOf (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.28 Include pending Laboratory Performer - documentationOf (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.14 Include active Insurance Card - participant (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.15 Include active Insurance - participant (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.13 Include active Document Replacement - relatedDocument (2017) DYNAMIC
2.16.756.5.30.1.1.10.3.3 Containment pending Laboratory Speciality Section - coded (2017) DYNAMIC
2.16.756.5.30.1.1.10.3.4 Containment pending Vital Signs Section - coded (2016) DYNAMIC
2.16.756.5.30.1.1.10.3.46 Containment pending Other Relevant Observations Section - coded (2018) DYNAMIC
2.16.756.5.30.1.1.10.3.53 Containment pending Current Pregnancy Section - coded (2018) DYNAMIC
2.16.756.5.30.1.1.10.3.45 Containment pending Original Representation Section - coded (2017) DYNAMIC
Relationship Specialization: template 2.16.756.5.30.1.1.10.1.14 (DYNAMIC)
Specialization: template 2.16.756.5.30.1.1.10.1.9 (DYNAMIC)
Specialization: template 2.16.840.1.113883.10.12.2 (2005‑09‑07)
Example
Example
<!-- See https://svn.code.sf.net/p/hl7ch/code/trunk/projects/eHealthSuisse/eLaborbefund/v1.0/ for examples -->
Item DT Card Conf Description Label
hl7:ClinicalDocument
1 … 1 M

Swiss Laboratory Report - General Report

Conformity rules that are not further modelled in ART-DECOR:

  • XML encoding
    UTF-8 encoding is required. All CDA-CH V2 documents MUST start with this line:
    <?xml version="1.0" encoding="UTF-8"?>

  • Phone numbers
    Phone numbers MUST be declared in the international format.
    Dots (.) MUST be used as separators for grouping of number blocks.
    The minus sign (-) MUST be used as a separator between public and internal telephone numbers. Purpose: Some telephone exchanges - especially in the US, allow direct dial-up of an internal telephone number after the actual connection has been established over the public telephone network.
    Examples:
    <telecom value="tel:+41.33.123.45.67"/>
    <telecom value="tel:+1.987.654.3210-999"/>

(CDAdots-V1)
Included 1 … 1 M from 2.16.756.5.30.1.1.10.2.25 Document Realm (DYNAMIC)
hl7:realmCode
CS 1 … 1 M Swiss Realm (CHE) of HL7 CDA. CDA‑CH V2
@code
CONF 1 … 1 F CHE
hl7:typeId
II 1 … 1 M (CDAdots-V1)
@root
uid 1 … 1 F 2.16.840.1.113883.1.3
@extension
st 1 … 1 F POCD_HD000040
Included from 2.16.756.5.30.1.1.10.2.18 Document Template Ids CDA-CH v2.0 - structuredBody (DYNAMIC)
hl7:templateId
II 0 … 1 CDA-CH v2.0 specification. This is an informational reference, only. CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.1.1.4
hl7:templateId
II 1 … 1 M HL7 CDA R2 (2005); contains ClinicalDocument.component as structuredBody. CDA‑CH V2
@root
uid 1 … 1 F 2.16.840.1.113883.10.12.2
hl7:templateId
II 1 … 1 M HL7 CDA R2 (2005). CDA‑CH V2
@root
uid 1 … 1 F 2.16.840.1.113883.10.12.1
Included from 2.16.756.5.30.1.1.10.2.55 Document Template Ids CDA-CH-LREP V1 (DYNAMIC)
hl7:templateId
II 0 … 1 CDA-CH-LREP / Laboratory Reports V1 specification. This is an informational reference, only. CDA‑dotsLREP
@root
uid 1 … 1 F 2.16.756.5.30.1.1.1.1.3.9.1
hl7:templateId
II 1 … 1 M Exchange format according to the Swiss EPR CDA‑dotsLREP
@root
uid 1 … 1 F 2.16.756.5.30.1.127.1.4
hl7:templateId
II 1 … 1 M Sharing Laboratory Reports (XD-LAB) Content Module, IHE PaLM Technical Framework Revision Revision 8.0 - June 21, 2017. CDA‑dotsLREP
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.3
hl7:templateId
II 1 … 1 M CDA-CH-LREP / Laboratory Reports V1 ART-DECOR model for General Report. (CDAdots-V1)
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.1.10
Included 1 … 1 M from 2.16.756.5.30.1.1.10.2.23 Document Id (DYNAMIC)
hl7:id
II 1 … 1 M A unique identifier for each CDA document instance. CDA‑CH V2
@root
uid 1 … 1 R The document's id as Globally Unique Identifier (GUID).
@extension
st 0 NP NP/not present
Included 1 … 1 M from 2.16.756.5.30.1.1.10.2.56 Document Code (DYNAMIC)
hl7:code
CE 1 … 1 M

A LOINC based document type of a CDA document instance including a translation to the Swiss EPR XDS.b metadata.

  • Multidisciplinary laboratory findings:
    The LOINC code of the document MUST read: 11502-2 (LABORATORY REPORT.TOTAL)
  • Laboratory reports of a single laboratory discipline:
    The LOINC code of the document MUST be taken from the value-set 'Laboratory Specialties'
IHE PalM TF3 Rev.8, 6.3.2.5
@code
cs 1 … 1 R The exact value of @code MUST either read '11502-2' or taken from the value-set 'Laboratory Specialties'.
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.6.1
@codeSystemName
st 1 … 1 F LOINC
@displayName
st 1 … 1 R The exact value of @displayName MUST either read 'LABORATORY REPORT.TOTAL' or taken from the value-set 'Laboratory Specialties'.
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.6 Multi-disciplinary Laboratory Report (DYNAMIC)
or
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.1 Laboratory Specialties (DYNAMIC)
hl7:translation
CD 1 … 1 R The translation to the Swiss EPR XDS.b metadata attribute typeCode. IHE PalM TF3 Rev.8, 6.3.2.5
@code
cs 1 … 1 F 4241000179101
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.6.96
@codeSystemName
st 1 … 1 F SNOMED CT
@displayName
st 1 … 1 F Laboratory report
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.127.3.10.1.27 EprDocumentTypeCode (DYNAMIC)
Included 1 … 1 M from 2.16.756.5.30.1.1.10.2.62 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‑dotsLREP
  Variable let Name languageCode  
  Value substring(/hl7:ClinicalDocument/hl7:languageCode/@code,1,2)  
  Schematron assert role red error  
  test not($languageCode='en') or starts-with(text(),'Laboratory report')  
  Message The English title must start with 'Laboratory report'  
  Schematron assert role red error  
  test not($languageCode='de') or starts-with(text(),'Laborbefund')  
  Message The German title must start with 'Laborbefund'  
  Schematron assert role red error  
  test not($languageCode='fr') or starts-with(text(),'Rapport de laboratoire')  
  Message The French title must start with 'Rapport de laboratoire'  
  Schematron assert role red error  
  test not($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. (CDAdots-V1)
Included 1 … 1 M from 2.16.756.5.30.1.1.10.2.19 Document Confidentiality Code (DYNAMIC)
hl7:confidentialityCode
CE (required) 1 … 1 M Swiss Realm of Confidentiality Code according to the Swiss EPR regulation. CDA‑CH V2
@code
cs 1 … 1 R The value of @code MUST be drawn from value set EprDocumentConfidentialityCode (2.16.756.5.30.1.127.3.10.1.5)
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.6.96
@codeSystemName
st 1 … 1 F SNOMED CT
@displayName
st 1 … 1 R The value of @displayName MUST be drawn from value set EprDocumentConfidentialityCode (2.16.756.5.30.1.127.3.10.1.5)
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.127.3.10.1.5 EprDocumentConfidentialityCode (DYNAMIC)
Included 1 … 1 M from 2.16.756.5.30.1.1.10.2.22 Document Language (DYNAMIC)
hl7:languageCode
CS 1 … 1 M The RFC 1766 (ISO-639-1 and ISO 3166) based language in which the narrative texts in this CDA document instance are written. CDA‑CH V2
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
Included 1 … 1 M from 2.16.756.5.30.1.1.10.2.20 Document Set Id and Version Number (DYNAMIC)
hl7:setId
II 1 … 1 M The setId element MUST match the document id of the very first version of that document. It MUST remain the same for all document versions. CDA‑CH V2
@root
uid 1 … 1 R The root attribute MUST contain the setId as Globally Unique Identifier (GUID).
@extension
st 0 NP NP/not present
  Schematron assert role red error  
  test (parent::*/hl7:versionNumber[@value='1'] and @root=parent::*/hl7:id/@root and (@extension=parent::*/hl7:id/@extension or (not(@extension) and not(parent::*/hl7:id/@extension)))) or (parent::*/hl7:versionNumber[not(@value ='1')] and ((@root=parent::*/hl7:id/@root and @extension and not(@extension=parent::*/hl7:id/@extension)) or(not(@root=parent::*/hl7:id/@root))))  
  Message The setId MUST be equal with the document id for version 1 and it MUST differ for all other versions.  
hl7:versionNumber
INT.NONNEG 1 … 1 M The versionNumber element MUST contain the value 1 for the very first version of that document. For later versions, the version number MUST be increased by 1 each. CDA‑CH V2
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).
Elements to choose from:
Included 0 … 1 from 2.16.756.5.30.1.1.10.2.58 Human 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‑dotsLREP
hl7:templateId
II 1 … 1 M CDA‑dotsLREP
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.58
hl7:templateId
II 1 … 1 M CDA‑dotsLREP
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.1
hl7:patientRole
1 … 1 R Exactly one patient MUST be declared. CDA‑dotsLREP
hl7:id
II 1 … * R At least one patient identification MUST be declared. CDA‑dotsLREP
@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.
@extension
st 0 … 1   Contains the patient number itself. The number MUST be unique within the system that has issued the number.
hl7:addr
AD 1 … * R All persons (including patients) and organizations, MUST according to XD-LAB contain name, addr and telecom.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑dotsLREP
hl7:telecom
TEL 1 … * R All persons (including patients) and organizations, MUST according to XD-LAB contain name, addr and telecom. CDA‑dotsLREP
hl7:patient
1 … 1 R Exactly one patient MUST be declared. CDA‑dotsLREP
hl7:name
PN 1 … * R All persons (including patients) and organizations, MUST according to XD-LAB contain name, addr and telecom. CDA‑dotsLREP
hl7:administrativeGenderCode
CE 1 … 1 R The sex of the patient MUST be indicated according to XD-LAB. CDA‑dotsLREP
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 AdministrativeGender (DYNAMIC)
hl7:birthTime
TS 1 … 1 R The date of birth of the patient MUST be given according to XD-LAB. CDA‑dotsLREP
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. IHE PalM TF3 Rev.8, 6.3.2.11.2
hl7:templateId
II 1 … 1 M IHE PalM TF3 Rev.8, 6.3.2.11.2
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.3.1.2
  Schematron assert role red 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:templateId
II 1 … 1 M IHE PalM TF3 Rev.8, 6.3.2.11.2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.26
hl7:patientRole
1 … 1 R IHE PalM TF3 Rev.8, 6.3.2.11.2
hl7:id
II 1 … * R IHE PalM TF3 Rev.8, 6.3.2.11.2
@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.
@extension
st 0 … 1   Contains the actual number of non-human material. The number MUST be unique within the system that issued the number.
hl7:patient
1 … 1 IHE PalM TF3 Rev.8, 6.3.2.11.2
@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. IHE PalM TF3 Rev.8, 6.3.2.11.3
hl7:templateId
II 1 … 1 M IHE PalM TF3 Rev.8, 6.3.2.11.3
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.3.1.3
  Schematron assert role red 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:templateId
II 1 … 1 M IHE PalM TF3 Rev.8, 6.3.2.11.3
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.27
hl7:patientRole
1 … 1 R Exactly one patient MUST be declared. IHE PalM TF3 Rev.8, 6.3.2.11.3
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).
IHE PalM TF3 Rev.8, 6.3.2.11.3
@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. IHE PalM TF3 Rev.8, 6.3.2.11.3
hl7:telecom
TEL 1 … * R All persons (including patients) and organizations, MUST contain according to XD-LAB name, addr and telecom. IHE PalM TF3 Rev.8, 6.3.2.11.3
hl7:patient
1 … 1 R Exactly one patient MUST be declared. IHE PalM TF3 Rev.8, 6.3.2.11.3
hl7:name
PN 1 … * R All persons (including patients) and organizations, MUST contain according to XD-LAB name, addr and telecom. IHE PalM TF3 Rev.8, 6.3.2.11.3
hl7:administrativeGenderCode
CE 1 … 1 R IHE PalM TF3 Rev.8, 6.3.2.11.3
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 AdministrativeGender (DYNAMIC)
hl7:birthTime
TS 1 … 1 R IHE PalM TF3 Rev.8, 6.3.2.11.3
Included 1 … * M from 2.16.756.5.30.1.1.10.2.59 Author (DYNAMIC)
hl7:author
1 … * M Information about the author of the document. The author MAY be a person or a device. At least one author MUST be declared. CDA‑dotsLREP
hl7:templateId
II 1 … 1 M CDA‑dotsLREP
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.59
hl7:templateId
II 1 … 1 M CDA‑dotsLREP
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.9.23
hl7:functionCode
CE 1 … 1 R The functionCode MUST be taken from the Swiss EPR Value-Set for author roles. See FDHA Ordinance on the Electronic Patient Record (EPRO-FDHA), Appendix 3: Metadata, Section 2.1.
If the desired functionCode is not available in the Swiss EPR Value-Set for author roles, nullFlavor='NAV' MUST be used. In this case, the originalText element MUST contain the description of the role.
Translations to other vocabularies are allowed.
CDA‑dotsLREP
@nullFlavor
st 0 … 1 F NAV
@code
cs 0 … 1  
@codeSystem
oid 0 … 1 F 2.16.840.1.113883.6.96
@codeSystemName
st 0 … 1 F SNOMED CT
@displayName
st 0 … 1  
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.127.3.10.1.1.3 EprAuthorRole (DYNAMIC)
  Example <functionCode code="106292003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Professional nurse"/>
  Example <functionCode nullFlavor="NAV">
  <originalText>Home helper</originalText></functionCode>
  Example <functionCode nullFlavor="NAV">
  <originalText>Laboratory technician</originalText>  <translation code="3212" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO-08" displayName="Medical and pathology laboratory technicians"/></functionCode>
  Schematron assert role red error  
  test (@code and @codeSystem) or (@nullFlavor='NAV')  
  Message Either a code with its code system or nullFlavor='NAV' is required.  
  Schematron assert role red error  
  test not(@nullFlavor) or (hl7:originalText)  
  Message Other Caregivers description MUST be declared in the originalText element in case of nullFlavor.  
hl7:translation
0 … * A translation of the code to another coding system (e.g. ISCO-08: 2.16.840.1.113883.2.9.6.2.7) CDA‑dotsLREP
@code
cs 1 … 1 R
@codeSystem
oid 1 … 1 R
@codeSystemName
st 1 … 1 R
@displayName
st 1 … 1 R
hl7:translation
0 … 1 Use this translation when the author is the patient itself (e.g. by reporting a self medication or a medical problem). CDA‑dotsLREP
@code
cs 1 … 1 F 116154003
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.6.96
@codeSystemName
st 1 … 1 F SNOMED CT
@displayName
st 1 … 1 F Patient (person)
hl7:time
TS.CH.TZ 1 … 1 R Date and time of the laboratory report creation. CDA‑dotsLREP
hl7:assignedAuthor
1 … 1 R CDA‑dotsLREP
  Schematron assert role red error  
  test not(hl7:assignedAuthoringDevice/hl7:softwareName) or (hl7:representedOrganization)  
  Message For device authors the element representedOrganization is REQUIRED.  
  Schematron assert role red error  
  test (hl7:telecom[@use='PUB' and starts-with(@value,'tel:+')]) and (hl7: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 red error  
  test (hl7:addr[@use='PUB'])  
  Message A public address is required.  
hl7:id
II 1 … 1 R The specification of GS1 GLN is REQUIRED. If it is not (yet) known, this MUST be declared using nullFlavor.
For persons: their personal GLN MUST be declared.
For devices or software modules: the GLN of their organization MUST be declared.
CDA‑dotsLREP
@nullFlavor
cs 0 … 1 F NAV
  Temporarily unknown, will be filled later.
@root
cs 0 … 1 F 2.51.1.3
  OID for GS1 GLN.
@extension
st 0 … 1   The GS1 GLN.
  Schematron assert role red 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 … * Other ids are allowed. CDA‑dotsLREP
@root
cs 1 … 1 R The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
@extension
st 0 … 1   The id itself. It MUST be unique within the issuing system.
hl7:addr
AD 1 … * Address of the laboratory.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑dotsLREP
hl7:telecom
TEL 1 … * Means of communication of the laboratory (phone, eMail, ...). CDA‑dotsLREP
Choice 1 … 1 Elements to choose from:
hl7:assignedPerson
0 … 1 The author as a person.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
CDA‑dotsLREP
hl7:assignedAuthoringDevice
0 … 1 The author as a device.
Contains 2.16.756.5.30.1.1.10.9.21 Device Compilation with name (DYNAMIC)
CDA‑dotsLREP
hl7:representedOrganization
0 … 1 The author's organization.
Contains 2.16.756.5.30.1.1.10.9.27 Organization Compilation with name, addr, telecom (DYNAMIC)
CDA‑dotsLREP
  Schematron assert role red error  
  test /hl7:ClinicalDocument/hl7:author/hl7:functionCode/hl7:translation[@code='3212' and @codeSystem='2.16.840.1.113883.2.9.6.2.7']  
  Message At least one of the listed authors MUST be a laboratory specialist.  
Included 0 … 1 from 2.16.756.5.30.1.1.10.2.7 Data Enterer (DYNAMIC)
hl7:dataEnterer
0 … 1 Information about the person that entered information in this CDA document. It SHALL be declared, when data recorded in this document has been entered by a person other than the author but only when this is relevant for some reason. CDA‑CH V2
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.7
hl7:time
TS.CH.TZ 0 … 1 Timestamp of the data input. CDA‑CH V2
hl7:assignedEntity
1 … 1 R Contains 2.16.756.5.30.1.1.10.9.12 Assigned Entity Compilation with id (DYNAMIC) CDA‑CH V2
Included 1 … 1 M from 2.16.756.5.30.1.1.10.2.60 Custodian (DYNAMIC)
hl7:custodian
1 … 1 M CDA‑dotsLREP
hl7:templateId
II 1 … 1 M CDA‑dotsLREP
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.3
hl7:templateId
II 1 … 1 M CDA‑dotsLREP
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.60
hl7:assignedCustodian
1 … 1 R CDA‑dotsLREP
hl7:representedCustodianOrganization
1 … 1 R CDA‑dotsLREP
  Schematron assert role red error  
  test (hl7:telecom[@use='PUB' and starts-with(@value,'tel:+')])  
  Message A public telephone number in the international format is required.  
  Schematron assert role red error  
  test (hl7: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‑dotsLREP
@nullFlavor
cs 0 … 1 F NAV
  Temporarily unknown, will be filled later.
@root
cs 0 … 1 F 2.51.1.3
  OID for GS1 GLN
@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).
  Schematron assert role red 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‑dotsLREP
@root
cs 1 … 1 F 2.16.756.5.30.1.123.100.2.1.1
  OID for SASIS number (ge:ZSR / fr:RCC).
@extension
st 1 … 1 R SASIS number (ge:ZSR / fr:RCC) of the laboratory or the physician.
hl7:name
ON 1 … 1 R Name of the laboratory. CDA‑dotsLREP
hl7:telecom
TEL 1 … * R Means of communication of the laboratory (phone., eMail, ...). CDA‑dotsLREP
hl7:addr
AD 1 … * R Address of the laboratory.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑dotsLREP
Included 1 … * M from 2.16.756.5.30.1.1.10.2.57 Recipient (DYNAMIC)
hl7:informationRecipient
1 … * M The laboratory report MUST contain at least one receiver. CDA‑dotsLREP
@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
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19366 x_InformationRecipient (DYNAMIC)
hl7:templateId
II 1 … 1 M CDA‑dotsLREP
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.4
hl7:templateId
II 1 … 1 M CDA‑dotsLREP
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.57
hl7:templateId
II 1 … 1 M CDA‑dotsLREP
@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‑dotsLREP
hl7:addr
AD 1 … * R An address MUST be present according to XD-LAB.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
CDA‑dotsLREP
hl7:telecom
TEL 1 … * R A communication mean MUST be present according to XD-LAB. CDA‑dotsLREP
hl7:informationRecipient
0 … 1 If the person of the recipient is used, it MUST according to XD-LAB declare a name.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
CDA‑dotsLREP
hl7:receivedOrganization
0 … 1 If the organization of the recipient is used, it MUST according to XD-LAB declare name, addr and telecom.
Contains 2.16.756.5.30.1.1.10.9.27 Organization Compilation with name, addr, telecom (DYNAMIC)
CDA‑dotsLREP
  Schematron assert role red error  
  test hl7:informationRecipient[not(@nullFlavor)] or hl7:receivedOrganization[not(@nullFlavor)]  
  Message Either the recipients person or organization MUST be declared.  
Included 0 … 1 from 2.16.756.5.30.1.1.10.2.61 Legal Authenticator (DYNAMIC)
hl7:legalAuthenticator
0 … 1 Legal authenticator. CDA‑dotsLREP
hl7:templateId
II 1 … 1 M CDA‑dotsLREP
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.61
hl7:templateId
II 1 … 1 M CDA‑dotsLREP
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.5
hl7:time
TS.CH.TZ 1 … 1 R Date of the signature. CDA‑dotsLREP
hl7:signatureCode
CS 1 … 1 R CDA‑dotsLREP
@code
cs 1 … 1 F S
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.1.11.10282
@codeSystemName
st 1 … 1 F ParticipationSignature
@displayName
st 1 … 1 F signed
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)
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 2.16.756.5.30.1.1.10.9.47 AssignedEntity Compilation for Laboratory (DYNAMIC)
CDA‑dotsLREP
hl7:authenticator
0 … * Contains 2.16.756.5.30.1.1.10.4.8 Laboratory Results Validator - authenticator/participant Containment (DYNAMIC) (CDAdots-V1)
treeblank where [hl7:templateId [@root = '2.16.756.5.30.1.1.10.4.8'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.3.1.5']]
Included 0 … 1 from 2.16.756.5.30.1.1.10.2.16 Order Reference - inFulfillmentOf (DYNAMIC)
hl7:inFulfillmentOf
0 … 1 Reference to one or more orders which led to the creation of this CDA document. It SHALL be declared, when the order reference is relevant for some reason. CDA‑CH V2
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.16
hl7:order
1 … 1 R CDA‑CH V2
hl7:id
II 1 … * R Order number. CDA‑CH V2
@root
uid 1 … 1 R Either the same GUID (order id) or the same OID (order issuing system) as the order itself.
@extension
st 0 … 1   Contains the order ID itself. The ID MUST be unique within the system that issued the ID.
Included 0 … 1 from 2.16.756.5.30.1.1.10.2.46 Health Service - documentationOf (DYNAMIC)
hl7:documentationOf
0 … 1 Information about a health service describing the context of this CDA document. CDA‑CH V2
@typeCode
cs 1 … 1 F DOC
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.46
hl7:serviceEvent
1 … 1 R CDA‑CH V2
@classCode
cs 1 … 1 F ACT
@moodCode
cs 1 … 1 F EVN
hl7:id
II 0 … * Health service identifiers such as case number ([ge]: Fallnummer; [fr]: Numéro de cas), consultation id, episode id, etc. CDA‑CH V2
@root
uid 1 … 1 R The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
@extension
st 0 … 1   The id itself. It MUST be unique within the issuing system.
hl7:code
CE 1 … 1 R As long as the eventCodeList for the Swiss EPR metadata is not defined yet by the FDHA Ordinance on the Electronic Patient Record (EPRO-FDHA), the nullFlavor='NAV' MUST be used in this template. Other codes MAY be declared as translation. CDA‑CH V2
@nullFlavor
st 1 … 1 F NAV
@code
cs 0 NP NP/not present
@codeSystem
oid 0 NP NP/not present
@codeSystemName
st 0 NP NP/not present
@displayName
st 0 NP NP/not present
hl7:translation
0 … * A translation of the code to another coding system. CDA‑CH V2
@code
cs 1 … 1 R
@codeSystem
oid 1 … 1 R
@codeSystemName
st 1 … 1 R
@displayName
st 1 … 1 R
hl7:effectiveTime
IVL_TS.CH.TZ 1 … 1 R Duration of the health service. CDA‑CH V2
hl7:low
TS.CH.TZ 1 … 1 R Start of the health service. CDA‑CH V2
hl7:high
TS.CH.TZ 1 … 1 R End of the health service. CDA‑CH V2
Included 0 … * from 2.16.756.5.30.1.1.10.9.31 Performer (DYNAMIC)
hl7:performer
0 … * Information about a healthcare provider who was the primary performer of the act. CDA‑CH V2
@typeCode
cs 1 … 1 F PRF
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.9.31
hl7:templateId
1 … 1 R CDA‑CH V2
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.1.24.3.5
hl7:functionCode
CE 1 … 1 R The functionCode MUST be taken from the Swiss EPR Value-Set for author roles. See FDHA Ordinance on the Electronic Patient Record (EPRO-FDHA), Appendix 3: Metadata, Section 2.1.
If the desired functionCode is not available in the Swiss EPR Value-Set for author roles, the code 133932002 (Other Caregiver) MUST be used. In this case, the originalText element MUST contain the description of the role.
Translations to other vocabularies are allowed.
CDA‑CH V2
@code
cs 1 … 1 R
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.6.96
@codeSystemName
st 1 … 1 F SNOMED CT
@displayName
st 1 … 1 R
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.127.3.10.1.1.3 EprAuthorRole (DYNAMIC)
  Example <functionCode code="106292003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Professional nurse"/>
  Example <functionCode code="133932002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Other Caregiver">
  <originalText>Home helper</originalText></functionCode>
  Example <functionCode code="133932002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Other Caregiver">
  <originalText>Laboratory technician</originalText>  <translation code="3212" codeSystem="2.16.840.1.113883.2.9.6.2.7" codeSystemName="ISCO-08" displayName="Medical and pathology laboratory technicians"/></functionCode>
  Schematron assert role red error  
  test not(@code='133932002') or (hl7:originalText/text())  
  Message Other Caregivers description MUST be declared in the originalText element.  
Included 0 … 1 C from 2.16.756.5.30.1.1.10.9.49 Original Text Reference (DYNAMIC)
The human-readable text MUST be generated automatically from the structured information of this element. The text element MUST contain the reference to the corresponding text in the human readable part, ONLY.
hl7:originalText
ED 0 … 1 C CDA‑CH V2
hl7:reference
TEL 1 … 1 M The reference to the corresponding text in the human readable part must be specified by reference to content[@ID]: reference[@value='#xxx'] CDA‑CH V2
@value
1 … 1 R Reference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding element.
  Schematron assert role red error  
  test starts-with(@value,'#')  
  Message The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding <content/> element.  
  Variable let Name idvalue  
  Value substring-after(@value,'#')  
  Schematron assert role red error  
  test ancestor::hl7:structuredBody//*[@ID=$idvalue]  
  Message No narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>').  
  Schematron assert role red error  
  test parent::*/text()=ancestor::hl7:structuredBody//*[@ID=$idvalue]/text()  
  Message The originalText content MUST be identical to the narrative text for this reference.  
hl7:translation
0 … * A translation of the code to another coding system (e.g. ISCO-08: 2.16.840.1.113883.2.9.6.2.7) CDA‑CH V2
@code
cs 1 … 1 R
@codeSystem
oid 1 … 1 R
@codeSystemName
st 1 … 1 R
@displayName
st 1 … 1 R
hl7:time
IVL_TS.CH.TZ 0 … 1 Duration of the performance. CDA‑CH V2
hl7:low
TS.CH.TZ 1 … 1 R Start of the performance. CDA‑CH V2
hl7:high
TS.CH.TZ 1 … 1 R End of the performance. CDA‑CH V2
hl7:assignedEntity
1 … 1 R Contains 2.16.756.5.30.1.1.10.9.32 Assigned Entity Compilation with id, name, addr, telecom, person and organization (DYNAMIC) CDA‑CH V2
Included 0 … * from 2.16.756.5.30.1.1.10.2.28 Laboratory Performer - documentationOf (DYNAMIC)
hl7:documentationOf
0 … * IHE PalM TF3 Rev.8, 6.3.2.20
hl7:templateId
II 1 … 1 M IHE PalM TF3 Rev.8, 6.3.2.20
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.28
hl7:serviceEvent
1 … 1 R IHE PalM TF3 Rev.8, 6.3.2.20
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. IHE PalM TF3 Rev.8, 6.3.2.20
hl7:performer
0 … * Laboratory Performer template in the CDA header.
Contains 2.16.756.5.30.1.1.10.4.7 Laboratory Performer - performer Containment (DYNAMIC)
IHE PalM TF3 Rev.8, 6.3.2.20
treeblank treeblank treeblank where [hl7:templateId [@root = '2.16.756.5.30.1.1.10.4.7'] and 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 - participant (DYNAMIC)
hl7:participant
0 … * Information on a patient's insurance card. CDA‑CH V2
@typeCode
cs 1 … 1 F HLD
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.14
hl7:time
IVL_TS.CH.TZ 1 … 1 R Validity period of the insurance card. CDA‑CH V2
hl7:low
TS.CH.TZ 1 … 1 CDA‑CH V2
@nullFlavor
cs 1 … 1 F NASK
hl7:high
TS.CH.TZ 1 … 1 R Expiration date of the insurance card. CDA‑CH V2
hl7:associatedEntity
1 … 1 R CDA‑CH V2
@classCode
cs 1 … 1 F POLHOLD
hl7:id
II 1 … 1 R The insurance card's id. CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.123.100.1.1.1
@extension
st 1 … 1 R Number of the insurance card.
hl7:associatedPerson
0 … 1 Family and given name on the insurance card.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
CDA‑CH V2
hl7:scopingOrganization
0 … 1 The insurance company which issued the insurance card.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC)
CDA‑CH V2
Included 0 … * from 2.16.756.5.30.1.1.10.2.15 Insurance - participant (DYNAMIC)
hl7:participant
0 … * Information on a patient's insurance. CDA‑CH V2
@typeCode
cs 1 … 1 F COV
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.15
hl7:time
IVL_TS.CH.TZ 0 … 1 Validity period of the contract. CDA‑CH V2
hl7:low
TS.CH.TZ 1 … 1 R Start of the contract. CDA‑CH V2
hl7:high
TS.CH.TZ 1 … 1 R End of the contract. CDA‑CH V2
hl7:associatedEntity
1 … 1 R CDA‑CH V2
@classCode
cs 1 … 1 F PAYOR
hl7:id
II 1 … 1 R The id of the contract ([ge]: Versichertennummer; [fr]: Numéro d'assuré). CDA‑CH V2
@root
uid 1 … 1 R The OID of the system that issued the id. OIDs of code systems, which are published in a public OID registry are REQUIRED. Others are NOT ALLOWED.
@extension
st 0 … 1   The id itself. It MUST be unique within the issuing system.
hl7:code
CE 1 … 1 R The underlying law for the contract. CDA‑CH V2
@nullFlavor
cs 0 … 1 F NAV
@code
cs 0 … 1   832.10, 832.20, 221.229.1, 833.1, 831.20
@codeSystem
oid 0 … 1 F 2.16.756.5.30.2.1.1.11
@codeSystemName
st 0 … 1 F ins-laws
@displayName
st 0 … 1   Federal Act on Health Insurance (HIA), Federal Act on Accident Insurance (AIA), Federal Act on Insurance Policies (Insurance Policies Act, IPA), Federal Act on Military Insurance (MilIA), Federal Act on Invalidity Insurance (InvIA)
  Schematron assert role red error  
  test (@nullFlavor='NAV' and not(@codeSystem or @codeSystemName or @code or @displayName)) or (@codeSystem='2.16.756.5.30.2.1.1.11' and @codeSystemName='ins-laws' and @code and @displayName)  
  Message Either a valid insurance law or nullFlavor="NAV" is REQUIRED.  
hl7:associatedPerson
0 … 1 Contact person at the insurance company.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
CDA‑CH V2
hl7:scopingOrganization
1 … 1 The insurance company.
Contains 2.16.756.5.30.1.1.10.9.26 Organization Compilation with GLN, name, addr and telecom (DYNAMIC)
CDA‑CH V2
treeblank treeblank treeblank where [hl7:id [@root = '2.51.1.3']]
Included 0 … * from 2.16.756.5.30.1.1.10.2.13 Document Replacement - relatedDocument (DYNAMIC)
hl7:relatedDocument
0 … *

Relationship to another CDA-CH V2 based document that is replaced by the current one.

Notes: For correction of wrong information, a new document that replaces the earlier document MUST be created. The new document corrects previously incorrect information. This also applies to the case where information in the CDA header has been corrected (e.g., if the original document has been issued to the wrong patient). While processing the new document at the recipient, all values from the previous document MUST be interpreted as deprecated (deleted/marked as deleted/deprecated) and all values in the new document MUST be marked as valid:

  • Values that were only contained in the previous document have to be treated as deleted.
  • Values that are present in both documents are overwritten with the contents of the new document.
  • Values that are only contained in the new document are to be added.
CDA‑CH V2
@typeCode
cs 1 … 1 F RPLC
  Indicates that it is a relationship to another document that needs to be replaced.
hl7:templateId
II 1 … 1 M CDA‑CH V2
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.2.13
hl7:parentDocument
1 … 1 R Relationship to the document that needs to be replaced. CDA‑CH V2
hl7:id
II 1 … 1 M The id of the document to be replaced MUST be declared. CDA‑CH V2
@root
uid 1 … 1 R The id (GUID) of the document to be replaced.
@extension
st 0 NP NP/not present
hl7:setId
II 1 … 1 M The setId of the document to be replaced MUST be declared. CDA‑CH V2
@extension
st 0 NP NP/not present
@root
uid 1 … 1 R The setId (GUID) of the document to be replaced and MUST be identical with the content of the setId of the current document.
  Schematron assert role red error  
  test (@root=/hl7:ClinicalDocument/hl7:id/@root) and not(@extension) and not(/hl7:ClinicalDocument/hl7:id/@extension)  
  Message ClinicalDocument/setId: MUST be identical to the one of the replaced document  
hl7:versionNumber
INT 1 … 1 M The version number of the document to be replaced. CDA‑CH V2
  Schematron assert role red error  
  test @value > /hl7:ClinicalDocument/hl7:versionNumber/@value  
  Message ClinicalDocument/versionNumber: MUST be higher than the one of the replaced document  
hl7:component
1 … 1 R (CDAdots-V1)
hl7:structuredBody
1 … 1 R (CDAdots-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 - coded (DYNAMIC)
(CDAdots-V1)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '2.16.756.5.30.1.1.10.3.3'] and 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.


Contains 2.16.756.5.30.1.1.10.3.4 Vital Signs Section - coded (DYNAMIC)
(CDAdots-V1)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '2.16.756.5.30.1.1.10.3.4'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.25'] and hl7:templateId [@root = '2.16.840.1.113883.10.20.1.16']]]
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 of the patient), if this is of particular interest to the interpretation of the laboratory results.


Contains 2.16.756.5.30.1.1.10.3.46 Other Relevant Observations Section - coded (DYNAMIC)
(CDAdots-V1)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '2.16.756.5.30.1.1.10.3.46'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.27'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.28']]]
hl7:component
0 … 1

Main section for a current pregnancy

A laboratory report MAY include a main section in the structuredBody element that contains information about a current pregnancy of the patient (e.g., estimated delivery date), if this is of particular interest to the interpretation of the laboratory results.


Contains 2.16.756.5.30.1.1.10.3.53 Current Pregnancy Section - coded (DYNAMIC)
(CDAdots-V1)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '2.16.756.5.30.1.1.10.3.53'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'] and hl7:templateId [@root = '2.16.756.5.30.1.127.77.1.10.1']]]
hl7:component
0 … 1

Main section for original representation

This section MAY be used to provide the original representation of the current CDA document as it has been seen by the legal authenticator while signing.


Contains 2.16.756.5.30.1.1.10.3.45 Original Representation Section - coded (DYNAMIC)
(CDAdots-V1)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '2.16.756.5.30.1.1.10.3.45']]]
  Schematron assert role orange warning  
  test not(//hl7:id[@root='2.16.756.5.30.1.127.3.10.3'])  
  Message This CDA-CH-LREP document contains a Swiss EPR-SPID. Please make sure, that this fits the legal base.  
  Schematron report role orange warning  
  test //hl7:id[@root=('2.16.756.5.31', '2.16.756.5.32')]/parent::hl7:patientRole  
  Message This CDA-CH-LREP document contains a Swiss Social Security number as patient identifier. Please make sure, that this fits the legal base.  
  Schematron assert role red error  
  test not(//hl7:id[@root=('2.16.756.5.30.1.127.3.10.3', '2.16.756.5.31', '2.16.756.5.32')]/../..[not(hl7:patientRole)])  
  Message Swiss EPR-SPID and Social Security numbers are not allowed in CDA-CH-LREP documents for other objects than the patient.