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ref Template  Laboratory Report Data Processing Entry

Id 2.16.756.5.30.1.1.10.4.4
ref
ch-palm-
 		Effective Date 2017‑06‑21
Other versions this id:
Status pending Under pre-publication review Version Label 2017
Name chpalm_entry_LaboratoryReportDataProcessingEntry Display Name Laboratory Report Data Processing Entry
Description Each chapter (Laboratory Speciality Section and Laboratory Report Item Section) MUST contain exactly one findings group (CDA Body Laboratory Report Data Processing Entry).
Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.4.4
Label IHE PalM TF3 Rev.8, 6.3.4.2
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 18 templates
Uses as Name Version
2.16.756.5.30.1.1.10.4.5 Containment pending Non-Human Subject - subject Containment (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.6 Containment pending Human Patient with Non-Human Subject - subject Containment (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.7 Containment pending Laboratory Performer - performer Containment (2017) DYNAMIC
2.16.756.5.30.1.1.10.9.16 Containment active Author Compilation with name, addr and telecom (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.8 Containment pending Laboratory Results Validator - authenticator/participant Containment (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.9 Containment pending Responsible Party - participant Containment (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.10 Containment pending Device - participant Containment (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.11 Containment pending Specimen Collection (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.12 Containment pending Specimen Received (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.13 Containment pending Notification Organizer (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.14 Containment pending Notifiable Condition (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.15 Containment pending Case Identification (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.16 Containment pending Outbreak Identification (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.17 Containment pending Laboratory Isolate Organizer (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.19 Containment pending Laboratory Battery Organizer (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.18 Containment pending Multimedia Embedded Content (2017) DYNAMIC
2.16.756.5.30.1.1.10.4.2 Containment pending Annotation Comments (2016) DYNAMIC
2.16.756.5.30.1.1.10.4.29 Containment pending External document (2017) DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.12.301 (2005‑09‑07)
Specialization: template 1.3.6.1.4.1.19376.1.3.1 (DYNAMIC)
Example
Example
<act classCode="ACT" moodCode="EVN">
  <templateId root="2.16.756.5.30.1.1.10.4.4"/>  <templateId root="1.3.6.1.4.1.19376.1.3.1"/>  <code code="18723-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HEMATOLOGY STUDIES"/>  <statusCode code="completed"/>  <!-- One of these templates:
2.16.756.5.30.1.1.10.4.15 - Case Identification
2.16.756.5.30.1.1.10.4.19 - Laboratory Battery Organizer
2.16.756.5.30.1.1.10.4.17 - Laboratory Isolate Organizer
2.16.756.5.30.1.1.10.4.18 - Multimedia Embedded Content
2.16.756.5.30.1.1.10.4.14 - Notifiable Condition
2.16.756.5.30.1.1.10.4.13 - Notification Organizer
2.16.756.5.30.1.1.10.4.16 - Outbreak Identification
2.16.756.5.30.1.1.10.4.11 - Specimen Collection
2.16.756.5.30.1.1.10.4.12 - Specimen Received
-->
</act>
Item DT Card Conf Description Label
hl7:act
 IHE PalM TF3 Rev.8, 6.3.4.2
@classCode
 cs 1 … 1 F ACT
@moodCode
 cs 1 … 1 F EVN
hl7:templateId
 II 1 … 1 M IHE PalM TF3 Rev.8, 6.3.4.2
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.1
hl7:templateId
 II 1 … 1 M IHE PalM TF3 Rev.8, 6.3.4.2
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.4.4
hl7:id
 II 0 … 1 An ID for this item MAY be filled for traceability. IHE PalM TF3 Rev.8, 6.3.4.2
@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 ID itself. The ID MUST be unique within the system that issued the ID.
hl7:code
 CD 1 … 1 M The same code as in the chapter (Laboratory Speciality Section Code or Laboratory Report Item Section Code) MUST be used. Both codes MUST be the identical. IHE PalM TF3 Rev.8, 6.3.4.2
@code
 st 1 … 1 R
@codeSystem
 oid 1 … 1 R
@codeSystemName
 st 1 … 1 R
@displayName
 st 1 … 1 R
hl7:text
 ED NP In the Laboratory Report Data Processing Entry, the text element is NOT PERMITTED for laboratory findings in Switzerland. IHE PalM TF3 Rev.8, 6.3.4.2
hl7:statusCode
 CS 1 … 1 M

The status 'completed' means that all expected results for this findings group are present and in a final state.

The status 'active' means that the examinations are still running. Some results are still pending.

The status 'aborted' means that the examinations had to be aborted. Some results MAY be available.

IHE PalM TF3 Rev.8, 6.3.4.2
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20309 ActStatusAbortedCancelledCompleted (DYNAMIC)
Choice 0 … 1
IF this findings group is based on a specimen of a non-human material, this MUST be declared with the subject element.
Elements to choose from:
hl7:subject
 0 … 1 Contains 2.16.756.5.30.1.1.10.4.5 Non-Human Subject - subject Containment (DYNAMIC) IHE PalM TF3 Rev.8, 6.3.4.2
treeblank treeblank where [hl7:templateId [@root = '2.16.756.5.30.1.1.10.4.5'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.3.1.2.1']]
hl7:subject
 0 … 1 Contains 2.16.756.5.30.1.1.10.4.6 Human Patient with Non-Human Subject - subject Containment (DYNAMIC) IHE PalM TF3 Rev.8, 6.3.4.2
treeblank treeblank where [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.3.1.3.1']]
hl7:performer
 0 … * This CAN be used to indicate who has performed the test. This information supersedes any information recorded at higher level.
Contains 2.16.756.5.30.1.1.10.4.7 Laboratory Performer - performer Containment (DYNAMIC) 		IHE PalM TF3 Rev.8, 6.3.4.2
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']]
hl7:author
 0 … * This CAN be used to indicate who has documented the result. This information supersedes any information recorded at higher level.
Contains 2.16.756.5.30.1.1.10.9.16 Author Compilation with name, addr and telecom (DYNAMIC) 		IHE PalM TF3 Rev.8, 6.3.4.2
treeblank where [hl7:functionCode [concat(@code, @codeSystem) = doc('include/voc-2.16.756.5.30.1.127.3.10.1.1.3-DYNAMIC.xml')//valueSet [1]/conceptList/concept/concat(@code, @codeSystem) or @nullFlavor]]
Choice 0 … *
This CAN be used to identify other parties:
  • Who has verified the result (AUTHEN).
  • Which external laboratory has delivered the result (RESP).
  • Which device (analyzer) was used to determine the result (DEV).
Elements to choose from:
hl7:participant
 0 … * Who has verified the result (AUTHEN). This information supersedes any information recorded at higher level.
Contains 2.16.756.5.30.1.1.10.4.8 Laboratory Results Validator - authenticator/participant Containment (DYNAMIC) 		IHE PalM TF3 Rev.8, 6.3.4.2
treeblank 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']]
hl7:participant
 0 … * Which external laboratory has delivered the result (RESP). This information supersedes any information recorded at higher level.
Contains 2.16.756.5.30.1.1.10.4.9 Responsible Party - participant Containment (DYNAMIC) 		IHE PalM TF3 Rev.8, 6.3.4.2
treeblank treeblank where [@typeCode = 'RESP'] [hl7:participantRole]
hl7:participant
 0 … * Which device (analyzer) was used to determine the result (DEV). This information supersedes any information recorded at higher level.
Contains 2.16.756.5.30.1.1.10.4.10 Device - participant Containment (DYNAMIC) 		IHE PalM TF3 Rev.8, 6.3.4.2
treeblank treeblank where [@typeCode = 'DEV'] [hl7:participantRole]
Choice 1 … *

A findings group may contain the following elements.

Note:The usage of Laboratory Observations, permitted by XD-LAB is NOT ALLOWED for this specification. Such Laboratory Observations MUST be placed in a Laboratory Battery Organizer.

Elements to choose from:
hl7:entryRelationship
 0 … * Contains 2.16.756.5.30.1.1.10.4.11 Specimen Collection (DYNAMIC) IHE PalM TF3 Rev.8, 6.3.4.2
treeblank treeblank where [hl7:procedure [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.1.2'] and hl7:templateId [@root = '2.16.756.5.30.1.1.10.4.11']]]
@typeCode
 cs 1 … 1 F COMP
hl7:entryRelationship
 0 … * Contains 2.16.756.5.30.1.1.10.4.12 Specimen Received (DYNAMIC) IHE PalM TF3 Rev.8, 6.3.4.2
treeblank treeblank where [hl7:act [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.1.3'] and hl7:templateId [@root = '2.16.756.5.30.1.1.10.4.12']]]
@typeCode
 cs 1 … 1 F COMP
hl7:entryRelationship
 0 … * Contains 2.16.756.5.30.1.1.10.4.13 Notification Organizer (DYNAMIC) IHE PalM TF3 Rev.8, 6.3.4.2
treeblank treeblank where [hl7:organizer [hl7:templateId [@root = '2.16.756.5.30.1.1.10.4.13'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.1.1']]]
@typeCode
 cs 1 … 1 F COMP
hl7:entryRelationship
 0 … * Contains 2.16.756.5.30.1.1.10.4.14 Notifiable Condition (DYNAMIC) IHE PalM TF3 Rev.8, 6.3.4.2
treeblank treeblank where [hl7:observation [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.1.1.1'] and hl7:templateId [@root = '2.16.756.5.30.1.1.10.4.14']]]
@typeCode
 cs 1 … 1 F COMP
hl7:entryRelationship
 0 … * Contains 2.16.756.5.30.1.1.10.4.15 Case Identification (DYNAMIC) IHE PalM TF3 Rev.8, 6.3.4.2
treeblank treeblank where [hl7:observation [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.1.1.2'] and hl7:templateId [@root = '2.16.756.5.30.1.1.10.4.15']]]
@typeCode
 cs 1 … 1 F COMP
hl7:entryRelationship
 0 … * Contains 2.16.756.5.30.1.1.10.4.16 Outbreak Identification (DYNAMIC) IHE PalM TF3 Rev.8, 6.3.4.2
treeblank treeblank where [hl7:observation [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.1.1.3'] and hl7:templateId [@root = '2.16.756.5.30.1.1.10.4.16']]]
@typeCode
 cs 1 … 1 F COMP
hl7:entryRelationship
 0 … * Contains 2.16.756.5.30.1.1.10.4.17 Laboratory Isolate Organizer (DYNAMIC) IHE PalM TF3 Rev.8, 6.3.4.2
treeblank treeblank where [hl7:organizer [hl7:templateId [@root = '2.16.756.5.30.1.1.10.4.17'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.1.5']]]
@typeCode
 cs 1 … 1 F COMP
hl7:entryRelationship
 0 … * Contains 2.16.756.5.30.1.1.10.4.19 Laboratory Battery Organizer (DYNAMIC) IHE PalM TF3 Rev.8, 6.3.4.2
treeblank treeblank where [hl7:organizer [hl7:templateId [@root = '2.16.756.5.30.1.1.10.4.19'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.1.4']]]
@typeCode
 cs 1 … 1 F COMP
hl7:entryRelationship
 0 … * Contains 2.16.756.5.30.1.1.10.4.18 Multimedia Embedded Content (DYNAMIC) IHE PalM TF3 Rev.8, 6.3.4.2
treeblank treeblank where [hl7:observationMedia [hl7:templateId [@root = '2.16.756.5.30.1.1.10.4.18'] and hl7:templateId [@root = '2.16.756.5.30.1.1.10.4.83']]]
@typeCode
 cs 1 … 1 F COMP
hl7:entryRelationship
 0 … * Contains 2.16.756.5.30.1.1.10.4.2 Annotation Comments (DYNAMIC) IHE PalM TF3 Rev.8, 6.3.4.2
treeblank treeblank where [hl7:act [hl7:templateId [@root = '2.16.756.5.30.1.1.10.4.2'] and hl7:templateId [@root = '2.16.840.1.113883.10.20.1.40'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.4.2']]]
@typeCode
 cs 1 … 1 F COMP
hl7:reference
 0 … * This CAN be used to make reference to an external document.
Contains 2.16.756.5.30.1.1.10.4.29 External document (DYNAMIC) 		IHE PalM TF3 Rev.8, 6.3.4.2
treeblank where [hl7:externalDocument [hl7:templateId [@root = '2.16.756.5.30.1.1.10.4.29']]]
@typeCode
 cs 1 … 1 F REFR
  Schematron assert role red error  
  test (hl7:code/@code=parent::hl7:entry/parent::hl7:section/hl7:code/@code) and (hl7:code/@codeSystem=parent::hl7:entry/parent::hl7:section/hl7:code/@codeSystem)  
  Message The code MUST be the identical to the one of the section.