Human Patient with Non-Human Subject (recordTarget)
Description
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.
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
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.
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).
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.
Template Human Patient with Non-Human Subject (recordTarget)
Draft
error