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ref Template  Laboratory Speciality Section

Id 2.16.756.5.30.1.1.10.3.3
ref
(from repository: ch-palm-)		 Effective Date valid from 2017‑03‑16 23:57:18
Status draft Draft Version Label 2017
Name chpalm_section_LaboratorySpecialty Display Name Laboratory Speciality Section
Description
Chapter (CDA Body Section) with laboratory results according to Sharing Laboratory Reports (XD-LAB) Content Module, IHE PaLM Technical Framework Revision 7.0 - July 5, 2016.
Each Laboratory Specialty Section contains laboratory tests of a particular discipline (e.g., microbiology or serology).
The Laboratory Specialty Section uses LOINC codes to define the appropriate discipline. Laboratory Specialty Sections MUST NOT be nested.
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.
  • Choice 2: Text and Entry
    With this option, the examination results MUST be documented in the text element of the section and the corresponding entry element (Laboratory Data Processing Entry).
    The human-readable text MUST be generated automatically from the entry and its sub-elements.
    For this purpose the presentation options according to the CDA Narrative Block schema (NarrativeBlock.xsd) may be used: tables, lists, paragraphs, hyperlinks, footnotes, references to attached or embedded multimedia objects.
If a document contains multiple Laboratory Specialty Sections, Choice 1 or Choice 2 can be selected for each individual chapter.
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
Used by as Name Version
2.16.756.5.30.1.1.1.1.3.9.1 Containment draft Laboratory Report V1 (2017) 2016‑03‑23
Uses as Name Version
2.16.756.5.30.1.1.10.3.5 Containment draft Laboratory Report Item Section (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.4 Containment draft Laboratory Report Data Processing Entry (2017) DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Specialization: template 1.3.6.1.4.1.19376.1.3.3.2.1 (2008‑08‑08)
Example
Specialty Section that holds a leaf section and Leaf Section that holds one Report Item
<section classCode="DOCSECT">
  <templateId root="1.3.6.1.4.1.19376.1.3.3.2.1"/>  <code code="18723-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HEMATOLOGY STUDIES"/>  <title>Laborbefund - Hämatologie</title>  <component>
    <section>
      <templateId root="1.3.6.1.4.1.19376.1.3.3.2.2"/>      <!-- Leaf Section that holds one Report Item -->
    </section>  </component></section>
Example
Specialty Section that holds Report Items directly as a Laboratory Report Data Processing Entry
<section classCode="DOCSECT">
  <templateId root="1.3.6.1.4.1.19376.1.3.3.2.1"/>  <code code="18719-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="CHEMISTRY STUDIES"/>  <title>Laborbefund - Chemie</title>  <text/>  <entry typeCode="DRIV">
    <templateId root="1.3.6.1.4.1.19376.1.3"/>    <act classCode="ACT" moodCode="EVN"> ... </act>  </entry></section>
Item DT Card Conf Description Label
hl7:section
 (chpalm_section_LaboratorySpecialty)
hl7:templateId
 II 1 … 1 M (chpalm_section_LaboratorySpecialty)
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.3.3
hl7:templateId
 II 1 … 1 M (chpalm_section_LaboratorySpecialty)
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.3.2.1
hl7:code
 CE 1 … 1 M This declares the laboratory discipline of the section. (chpalm_section_LaboratorySpecialty)
@code
 1 … 1 R
@codeSystem
 oid 1 … 1 F 2.16.840.1.113883.6.1
@codeSystemName
 st 1 … 1 F LOINC
@displayName
 1 … 1 R The displayName of the code MUST be specified for tracking purposes. However, processing is NOT ALLOWED. Instead, a processing system is to display a user readable language translation of the code from the value set.
  CONF
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:title
 ST 1 … 1 R The title of the chapter MUST be specified and correspond to the following text format, where <human readable code> contains the corresponding translation of the document LOINC code:
  • [ge]: 'Laborbefund - <human readable code>'
  • [fr]: 'Rapport de laboratoire - <human readable code>'
  • [it]: 'Referto di laboratorio - <human readable code>'
  • [en]: 'Laboratory Specialty - <human readable code>'

The following translations of the LOINC codes given in XD-LAB MUST be used:
LOINC Code Text
18717-9 [ge]: Immunhämatologie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18718-7 [ge]: Molekularbiologie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18719-5 [ge]: Chemie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18720-3 [ge]: Gerinnung
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18721-1 [ge]: Medikamente
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18722-9 [ge]: Fertilität
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18723-7 [ge]: Hämatologie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18724-5 [ge]: HLA
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18725-2 [ge]: Mikrobiologie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18727-8 [ge]: Serologie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18728-6 [ge]: Toxikologie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18729-4 [ge]: Urin Untersuchungen
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18767-4 [ge]: Blutgase
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18768-2 [ge]: Differenzialblutbild
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
18769-0 [ge]: Antibiogramme
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
26435-8 [ge]: Molekulare Pathologie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
26436-6 [ge]: Laboruntersuchungen
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
26437-4 [ge]: Stimulationen
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
26438-2 [ge]: Zytologie
[fr]: TOTRANSLATE
[it]: TOTRANSLATE
(chpalm_section_LaboratorySpecialty)
  Example
Deutsch
<title>Laborbefund - Immunhämatologie</title>
  Example
Englisch
<title>Laboratory Specialty - Blood Bank Studies</title>
Choice 1 … * Elements to choose from:
hl7:component
 0 … * C Contains 2.16.756.5.30.1.1.10.3.5 Laboratory Report Item Section (DYNAMIC) (chpalm_section_LaboratorySpecialty)
treeblank treeblank where [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.3.2.2']]]
hl7:entry
 0 … * C Contains 2.16.756.5.30.1.1.10.4.4 Laboratory Report Data Processing Entry (DYNAMIC) (chpalm_section_LaboratorySpecialty)
treeblank treeblank where [hl7:act [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.1']]]
@typeCode
 cs 1 … 1 F DRIV
  Schematron assert role red error  
  test (hl7:component and not(hl7:text or hl7:entry)) or (not(hl7:component) and hl7:text and hl7:entry)  
  Message 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.