Template  General Laboratory Report

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"/>

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'

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>'

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.

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.

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.

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.

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.

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.