Template 2.16.756.5.30.1.1.10.2.27 - chpalm_header_RecordTargetHumanPatientWithNonHumanSubject

Template Human Patient with Non-Human Subject - recordTarget

2.16.756.5.30.1.1.10.2.27

ref

ch-palm-

Effective Date

2017‑06‑21

Status Under pre-publication review Version Label 2017

Name chpalm_header_RecordTargetHumanPatientWithNonHumanSubject Display Name 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.

Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.2.27

Label IHE PalM TF3 Rev.8, 6.3.2.11.3

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

Relationship Specialization: template 2.16.840.1.113883.10.12.101 (2005‑09‑07)
Specialization: template 1.3.6.1.4.1.19376.1.3.3.1.3 (2008‑08‑08)

Example

Human patient paired with Non-Human Subject Example

<recordTarget typeCode="RCT"> <templateId root="1.3.6.1.4.1.19376.1.3.3.1.3"/> <patientRole classCode="PAT"> <id root="2.999" extension="sw54321"/> <addr> <streetAddressLine>Leidensweg 10</streetAddressLine> <city>Specimendorf</city> <postalCode>9876</postalCode> </addr> <telecom value="tel:+41.32.685.12.34"/> <patient classCode="PSN"> <name> <family>Muster</family> <given>Max</given> </name> <administrativeGenderCode code="F"/> <birthTime value="19480611"/> </patient> </patientRole></recordTarget>

Item DT Card Conf Description Label

hl7:recordTarget 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 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

Template Human Patient with Non-Human Subject - recordTarget