hl7:ClinicalDocument
|
|
1 … 1 |
M |
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"/>
|
(CDA -V1) |
| Included |
1 … 1 |
M |
from 2.16.756.5.30.1.1.10.2.25 Document Realm (DYNAMIC)
|
hl7:realmCode
|
CS |
1 … 1 |
M |
Swiss Realm (CHE) of HL7 CDA. |
CDA‑CH V2 |
@code
|
CONF |
1 … 1 |
F |
CHE |
hl7:typeId
|
II |
1 … 1 |
M |
|
(CDA-V1) |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.1.3 |
@extension
|
st |
1 … 1 |
F |
POCD_HD000040 |
| Included |
|
|
from 2.16.756.5.30.1.1.10.2.18 Document Template Ids CDA-CH v2.0 - structuredBody (DYNAMIC)
|
hl7:templateId
|
II |
0 … 1 |
|
CDA-CH v2.0 specification. This is an informational reference, only. |
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.1.1.4 |
hl7:templateId
|
II |
1 … 1 |
M |
CDA-CH v2.0 structuredBody |
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.1.9 |
hl7:templateId
|
II |
1 … 1 |
M |
HL7 CDA R2 (2005); contains ClinicalDocument.component as structuredBody. |
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.10.12.2 |
hl7:templateId
|
II |
1 … 1 |
M |
HL7 CDA R2 (2005). |
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.10.12.1 |
| Included |
|
|
from 2.16.756.5.30.1.1.10.2.55 Document Template Ids CDA-CH-LREP V1 (DYNAMIC)
|
hl7:templateId
|
II |
0 … 1 |
|
CDA-CH-LREP / Laboratory Reports V1 specification. This is an informational reference,
only.
|
CDA‑LREP |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.1.1.3.9.1 |
hl7:templateId
|
II |
1 … 1 |
M |
Exchange format according to the Swiss EPR |
CDA‑LREP |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.127.1.4 |
hl7:templateId
|
II |
1 … 1 |
M |
Sharing Laboratory Reports (XD-LAB) Content Module, IHE PaLM Technical Framework Revision
Revision 8.0 - June 21, 2017.
|
CDA‑LREP |
@root
|
uid |
1 … 1 |
F |
1.3.6.1.4.1.19376.1.3.3 |
hl7:templateId
|
II |
1 … 1 |
M |
CDA-CH-LREP / Laboratory Reports V1 ART-DECOR model for General Report. |
(CDA-V1) |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.1.10 |
| Included |
1 … 1 |
M |
from 2.16.756.5.30.1.1.10.2.23 Document Id (DYNAMIC)
|
hl7:id
|
II |
1 … 1 |
M |
A unique identifier for each CDA document instance. |
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
R |
The document's id as Globally Unique Identifier (GUID). |
@extension
|
st |
0 |
NP |
NP/not present |
| Included |
1 … 1 |
M |
from 2.16.756.5.30.1.1.10.2.56 Document Code (DYNAMIC)
|
hl7:code
|
CE |
1 … 1 |
M |
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'
|
IHE PalM TF3 Rev.10, 6.3.2.5 |
@code
|
cs |
1 … 1 |
R |
The exact value of @code MUST either read '11502-2' or taken from the value-set 'Laboratory
Specialties'.
|
@codeSystem
|
oid |
1 … 1 |
F |
2.16.840.1.113883.6.1 |
@codeSystemName
|
st |
1 … 1 |
F |
LOINC |
@displayName
|
st |
1 … 1 |
R |
The exact value of @displayName MUST either read 'LABORATORY REPORT.TOTAL' or taken
from the value-set 'Laboratory Specialties'.
|
| |
CONF |
|
hl7:translation
|
CD |
1 … 1 |
R |
A translation to the Swiss EPR XDS.b metadata. |
IHE PalM TF3 Rev.10, 6.3.2.5 |
@code
|
cs |
1 … 1 |
F |
4241000179101 |
@codeSystem
|
oid |
1 … 1 |
F |
2.16.840.1.113883.6.96 |
@codeSystemName
|
st |
1 … 1 |
F |
SNOMED CT |
@displayName
|
st |
1 … 1 |
F |
Laboratory report |
| |
CONF |
|
| Included |
1 … 1 |
M |
from 2.16.756.5.30.1.1.10.2.62 Document Title (DYNAMIC)
|
hl7:title
|
ST |
1 … 1 |
M |
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>'
|
CDA‑LREP |
| |
Variable let |
Name |
languageCode |
|
| |
Value |
substring(/hl7:ClinicalDocument/hl7:languageCode/@code,1,2) |
|
| |
Schematron assert |
role |
 error
|
|
| |
test |
not($languageCode='en') or starts-with(text(),'Laboratory report') |
|
| |
Message |
The English title must start with 'Laboratory report' |
|
| |
Schematron assert |
role |
error
|
|
| |
test |
not($languageCode='de') or starts-with(text(),'Laborbefund') |
|
| |
Message |
The German title must start with 'Laborbefund' |
|
| |
Schematron assert |
role |
error
|
|
| |
test |
not($languageCode='fr') or starts-with(text(),'Rapport de laboratoire') |
|
| |
Message |
The French title must start with 'Rapport de laboratoire' |
|
| |
Schematron assert |
role |
error
|
|
| |
test |
not($languageCode='it') or starts-with(text(),'Rapporto di laboratorio') |
|
| |
Message |
The Italian title must start with 'Rapporto di laboratorio' |
|
hl7:effectiveTime
|
TS.CH.TZ |
1 … 1 |
M |
ClinicalDocument/effectiveTime MUST exist. It contains the creation date and time
of the laboratory report. If this document replaces a previous version (linked via
parentDocument), this is the date and time of the new version.
|
(CDA-V1) |
| Included |
1 … 1 |
M |
from 2.16.756.5.30.1.1.10.2.19 Document Confidentiality Code (DYNAMIC)
|
hl7:confidentialityCode
|
CE (required) |
1 … 1 |
M |
Swiss Realm of Confidentiality Code according to the Swiss EPR regulation. |
CDA‑CH V2 |
@code
|
cs |
1 … 1 |
R |
The value of @code MUST be drawn from value set DocumentEntry.confidentialityCode |
@codeSystem
|
oid |
1 … 1 |
R |
|
@codeSystemName
|
st |
1 … 1 |
R |
|
@displayName
|
st |
1 … 1 |
R |
The value of @displayName MUST be drawn from value set DocumentEntry.confidentialityCode |
| |
CONF |
|
| Included |
1 … 1 |
M |
from 2.16.756.5.30.1.1.10.2.22 Document Language (DYNAMIC)
|
hl7:languageCode
|
CS |
1 … 1 |
M |
The RFC5646 based language in which the narrative texts in this CDA document instance
are written.
|
CDA‑CH V2 |
| |
CONF |
|
| Included |
1 … 1 |
M |
from 2.16.756.5.30.1.1.10.2.20 Document Set Id and Version Number (DYNAMIC)
|
hl7:setId
|
II |
1 … 1 |
M |
The setId element MUST match the document id of the very first version of that document.
It MUST remain the same for all document versions.
|
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
R |
The root attribute MUST contain the setId as Globally Unique Identifier (GUID). |
@extension
|
st |
0 |
NP |
NP/not present |
| |
Schematron assert |
role |
error
|
|
| |
test |
(parent::*/hl7:versionNumber[@value='1'] and @root=parent::*/hl7:id/@root and (@extension=parent::*/hl7:id/@extension
or (not(@extension) and not(parent::*/hl7:id/@extension)))) or (parent::*/hl7:versionNumber[not(@value
='1')] and ((@root=parent::*/hl7:id/@root and @extension and not(@extension=parent::*/hl7:id/@extension))
or(not(@root=parent::*/hl7:id/@root))))
|
|
| |
Message |
The setId MUST be equal with the document id for version 1 and it MUST differ for
all other versions. |
|
hl7:versionNumber
|
INT.NONNEG |
1 … 1 |
M |
The versionNumber element MUST contain the value 1 for the very first version of that
document. For later versions, the version number MUST be increased by 1 each.
|
CDA‑CH V2 |
| Choice |
1 … 1 |
|
recordTarget MUST be present in one of the following characteristics:
- Human Patient: The laboratory report contain test results from samples taken exclusively
from a human patient.
- Non-Human Subject: The laboratory report contains test results from samples taken
from a non-human material (e.g., water, milk, etc.) or a living being (e.g., animal),
but not related to a human patient.
- Human Patient with Non-Human Subject: The laboratory report contains test results
from samples taken from a non-human material that is related to a human patient (e.g.,
food eaten by the patient or animal that has bitten the patient).
|
| Included |
0 … 1 |
|
from 2.16.756.5.30.1.1.10.2.58 Human Patient - recordTarget (DYNAMIC)
Human Patient: The laboratory results contain test results from samples taken exclusively
from a human patient. All persons (including patients) and organizations, MUST according
to XD-LAB contain name, addr and telecom.
|
hl7:recordTarget
|
|
0 … 1 |
R |
Patient (Human Patient). |
CDA‑LREP |
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑LREP |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.58 |
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑LREP |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.1 |
hl7:patientRole
|
|
1 … 1 |
R |
Exactly one patient MUST be declared. |
CDA‑LREP |
hl7:id
|
II |
1 … * |
R |
At least one patient identification MUST be declared. |
CDA‑LREP |
@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 patient number itself. The number MUST be unique within the system that
has issued the number.
|
hl7:addr
|
AD |
1 … * |
R |
All persons (including patients) and organizations, MUST according to XD-LAB contain
name, addr and telecom.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
|
CDA‑LREP |
hl7:telecom
|
TEL |
1 … * |
R |
All persons (including patients) and organizations, MUST according to XD-LAB contain
name, addr and telecom.
|
CDA‑LREP |
hl7:patient
|
|
1 … 1 |
R |
Exactly one patient MUST be declared. |
CDA‑LREP |
hl7:name
|
PN |
1 … * |
R |
All persons (including patients) and organizations, MUST according to XD-LAB contain
name, addr and telecom.
|
CDA‑LREP |
hl7:administrativeGenderCode
|
CE |
1 … 1 |
R |
The patient's gender. |
CDA‑LREP |
@nullFlavor
|
cs |
0 … 1 |
|
|
@code
|
cs |
0 … 1 |
|
|
@codeSystem
|
oid |
0 … 1 |
F |
2.16.840.1.113883.5.1 |
@codeSystemName
|
st |
0 … 1 |
F |
HL7 AdministrativeGender |
@displayName
|
st |
0 … 1 |
|
|
| |
Schematron assert |
role |
error
|
|
| |
test |
(not(@nullFlavor) and @displayName and @code and @codeSystem and @codeSystemName)
or (@nullFlavor and not(@displayName or @code or @codeSystem or @codeSystemName))
|
|
| |
Message |
Either nullFlavor or a valid code is required. |
|
hl7:birthTime
|
TS |
1 … 1 |
R |
The date of birth of the patient MUST be given according to XD-LAB. |
CDA‑LREP |
| Included |
0 … 1 |
|
from 2.16.756.5.30.1.1.10.2.26 Non-Human Subject - recordTarget (DYNAMIC)
Non-Human Subject: The laboratory report contains test results from samples taken
from a non-human material (e.g., water, milk, etc.) or a living being (e.g., animal),
but not related to a human patient.
|
hl7:recordTarget
|
|
0 … 1 |
R |
Non-Human Subject. |
IHE PalM TF3 Rev.10, 6.3.2.11.2 |
hl7:templateId
|
II |
1 … 1 |
M |
|
IHE PalM TF3 Rev.10, 6.3.2.11.2 |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.26 |
hl7:templateId
|
II |
1 … 1 |
M |
|
IHE PalM TF3 Rev.10, 6.3.2.11.2 |
@root
|
uid |
1 … 1 |
F |
1.3.6.1.4.1.19376.1.3.3.1.2 |
| |
Schematron assert |
role |
error
|
|
| |
test |
//hl7:templateId[@root='1.3.6.1.4.1.19376.1.3.3.1.2.1'] |
|
| |
Message |
In addition to the elements specified in the CDA header for the non-human subject,
this non-human subject SHALL be represented in a Subject element in level 3 entries
in the structuredBody. |
|
hl7:patientRole
|
|
1 … 1 |
R |
|
IHE PalM TF3 Rev.10, 6.3.2.11.2 |
hl7:id
|
II |
1 … * |
R |
|
IHE PalM TF3 Rev.10, 6.3.2.11.2 |
@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.
|
@extension
|
st |
0 … 1 |
|
Contains the actual number of non-human material. The number MUST be unique within
the system that issued the number.
|
hl7:patient
|
|
1 … 1 |
|
|
IHE PalM TF3 Rev.10, 6.3.2.11.2 |
@nullFlavor
|
cs |
1 … 1 |
F |
OTH |
| |
Indicates that there are laboratory tests for this non-human material in the CDA Body. |
| Included |
0 … 1 |
|
from 2.16.756.5.30.1.1.10.2.27 Human Patient with Non-Human Subject - recordTarget (DYNAMIC)
Human Patient with Non-Human Subject: The laboratory report contains test results
from samples taken from a non-human material that is related to a human patient (e.g.,
food eaten by the patient or animal that has bitten the patient).
|
hl7:recordTarget
|
|
0 … 1 |
R |
Human Patient with Non-Human Subject. |
IHE PalM TF3 Rev.10, 6.3.2.11.3 |
hl7:templateId
|
II |
1 … 1 |
M |
|
IHE PalM TF3 Rev.10, 6.3.2.11.3 |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.27 |
hl7:templateId
|
II |
1 … 1 |
M |
|
IHE PalM TF3 Rev.10, 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:patientRole
|
|
1 … 1 |
R |
Exactly one patient MUST be declared. |
IHE PalM TF3 Rev.10, 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 declared 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.10, 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.10, 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.10, 6.3.2.11.3 |
hl7:patient
|
|
1 … 1 |
R |
Exactly one patient MUST be declared. |
IHE PalM TF3 Rev.10, 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.10, 6.3.2.11.3 |
hl7:administrativeGenderCode
|
CE |
1 … 1 |
R |
|
IHE PalM TF3 Rev.10, 6.3.2.11.3 |
| |
CONF |
|
hl7:birthTime
|
TS |
1 … 1 |
R |
|
IHE PalM TF3 Rev.10, 6.3.2.11.3 |
| Included |
1 … * |
M |
from 2.16.756.5.30.1.1.10.2.59 Author (DYNAMIC)
|
hl7:author
|
|
1 … * |
M |
Information about the author of the document. The author MAY be a person or a device.
At least one author MUST be declared.
|
CDA‑LREP |
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑LREP |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.59 |
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑LREP |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.9.23 |
hl7:functionCode
|
CE |
0 … 1 |
|
|
CDA‑LREP |
| |
CONF |
|
hl7:time
|
TS.CH.TZ |
1 … 1 |
R |
Date and time of the laboratory report creation. |
CDA‑LREP |
hl7:assignedAuthor
|
|
1 … 1 |
R |
|
CDA‑LREP |
| |
Schematron assert |
role |
error
|
|
| |
test |
not(hl7:assignedAuthoringDevice/hl7:softwareName) or (hl7:representedOrganization) |
|
| |
Message |
For device authors the element representedOrganization is REQUIRED. |
|
| |
Schematron assert |
role |
error
|
|
| |
test |
(hl7:telecom[@use='PUB' and starts-with(@value,'tel:+')]) and (hl7:telecom[@use='PUB'
and starts-with(@value,'mailto:')])
|
|
| |
Message |
A public telephone number in the international format and a public eMail address are
required. |
|
| |
Schematron assert |
role |
error
|
|
| |
test |
(hl7:addr[@use='PUB']) |
|
| |
Message |
A public address is required. |
|
hl7:id
|
II |
1 … 1 |
R |
The specification of GS1 GLN is REQUIRED. If it is not (yet) known, this MUST be
declared using nullFlavor.
For persons: their personal GLN MUST be declared.
For devices or software modules: the GLN of their organization MUST be declared.
|
CDA‑LREP |
@nullFlavor
|
cs |
0 … 1 |
F |
NAV |
| |
Temporarily unknown, will be filled later. |
@root
|
cs |
0 … 1 |
F |
2.51.1.3 |
| |
OID for GS1 GLN. |
@extension
|
st |
0 … 1 |
|
The GS1 GLN. |
| |
Schematron assert |
role |
error
|
|
| |
test |
(@root='2.51.1.3' and @extension) or (@nullFlavor='NAV') |
|
| |
Message |
Either the GS1 GLN or nullFlavor='NAV' is REQUIRED |
|
hl7:id
|
II |
0 … * |
|
Other ids are allowed. |
CDA‑LREP |
@root
|
cs |
1 … 1 |
R |
The OID of the system that issued the id. OIDs of code systems, which are published
in a public OID registry are REQUIRED. Others are NOT ALLOWED.
|
@extension
|
st |
0 … 1 |
|
The id itself. It MUST be unique within the issuing system. |
hl7:addr
|
AD |
1 … * |
|
Address of the laboratory.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
|
CDA‑LREP |
hl7:telecom
|
TEL |
1 … * |
|
Means of communication of the laboratory (phone, eMail, ...). |
CDA‑LREP |
| Choice |
1 … 1 |
|
Elements to choose from:
|
hl7:assignedPerson
|
|
0 … 1 |
|
The author as a person.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
|
CDA‑LREP |
hl7:assignedAuthoringDevice
|
|
0 … 1 |
|
The author as a device.
Contains 2.16.756.5.30.1.1.10.9.21 Device Compilation with name (DYNAMIC)
|
CDA‑LREP |
hl7:representedOrganization
|
|
0 … 1 |
|
The author's organization.
Contains 2.16.756.5.30.1.1.10.9.27 Organization Compilation with name, addr, telecom (DYNAMIC)
|
CDA‑LREP |
| |
Schematron assert |
role |
error
|
|
| |
test |
/hl7:ClinicalDocument/hl7:author/hl7:functionCode/hl7:translation[@code='3212' and
@codeSystem='2.16.840.1.113883.2.9.6.2.7']
|
|
| |
Message |
At least one of the listed authors MUST be a laboratory specialist. |
|
| Included |
0 … 1 |
|
from 2.16.756.5.30.1.1.10.2.7 Data Enterer (DYNAMIC)
|
hl7:dataEnterer
|
|
0 … 1 |
|
Information about the person that entered information in this CDA document. It SHALL
be declared, when data recorded in this document has been entered by a person other
than the author but only when this is relevant for some reason.
|
CDA‑CH V2 |
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.7 |
hl7:time
|
TS.CH.TZ |
0 … 1 |
|
Timestamp of the data input. |
CDA‑CH V2 |
hl7:assignedEntity
|
|
1 … 1 |
R |
Contains 2.16.756.5.30.1.1.10.9.12 Assigned Entity Compilation with id (DYNAMIC)
|
CDA‑CH V2 |
| Included |
1 … 1 |
M |
from 2.16.756.5.30.1.1.10.2.60 Custodian (DYNAMIC)
|
hl7:custodian
|
|
1 … 1 |
M |
|
CDA‑LREP |
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑LREP |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.3 |
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑LREP |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.60 |
hl7:assignedCustodian
|
|
1 … 1 |
R |
|
CDA‑LREP |
hl7:representedCustodianOrganization
|
|
1 … 1 |
R |
|
CDA‑LREP |
| |
Schematron assert |
role |
error
|
|
| |
test |
(hl7:telecom[@use='PUB' and starts-with(@value,'tel:+')]) |
|
| |
Message |
A public telephone number in the international format is required. |
|
| |
Schematron assert |
role |
error
|
|
| |
test |
(hl7:addr[@use='PUB']) |
|
| |
Message |
A public address is required. |
|
hl7:id
|
II |
1 … * |
R |
The specification of GS1 GLN is required. If it is not (yet) known, this must be declared
using nullFlavor.
|
CDA‑LREP |
@nullFlavor
|
cs |
0 … 1 |
F |
NAV |
| |
Temporarily unknown, will be filled later. |
@root
|
cs |
0 … 1 |
F |
2.51.1.3 |
| |
OID for GS1 GLN |
@extension
|
st |
0 … 1 |
|
The GS1 GLN of the laboratory or the doctor's office (in the case of individual practices,
the doctor's GLN).
|
| |
Schematron assert |
role |
error
|
|
| |
test |
(@root='2.51.1.3' and @extension) or (@nullFlavor='NAV') |
|
| |
Message |
Either the GS1 GLN or nullFlavor='NAV' is required. |
|
hl7:id
|
II |
0 … * |
C |
SASIS number (ge:ZSR / fr:RCC), if the lab services are to be refunded by the insurance. |
CDA‑LREP |
@root
|
cs |
1 … 1 |
F |
2.16.756.5.30.1.123.100.2.1.1 |
| |
OID for SASIS number (ge:ZSR / fr:RCC). |
@extension
|
st |
1 … 1 |
R |
SASIS number (ge:ZSR / fr:RCC) of the laboratory or the physician. |
hl7:name
|
ON |
1 … 1 |
R |
Name of the laboratory. |
CDA‑LREP |
hl7:telecom
|
TEL |
1 … 1 |
R |
Means of communication of the laboratory (phone., eMail, ...). |
CDA‑LREP |
hl7:addr
|
AD |
1 … 1 |
R |
Address of the laboratory.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
|
CDA‑LREP |
| Included |
1 … * |
M |
from 2.16.756.5.30.1.1.10.2.57 Recipient (DYNAMIC)
|
hl7:informationRecipient
|
|
1 … * |
M |
The laboratory report MUST contain at least one receiver. |
CDA‑LREP |
@typeCode
|
cs |
1 … 1 |
R |
The main recipient of the document MUST be specified using typeCode 'PRCP' (primary
recipient). Other receivers (copy to; Cc) MUST be specified using typeCode 'TRC' (tracker).
|
| |
CONF |
|
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑LREP |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.4 |
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑LREP |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.57 |
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑LREP |
@root
|
uid |
1 … 1 |
F |
1.3.6.1.4.1.19376.1.3.3.1.4 |
hl7:intendedRecipient
|
|
1 … 1 |
M |
The laboratory report MUST contain at least one receiver. |
CDA‑LREP |
hl7:addr
|
AD |
1 … * |
R |
An address MUST be present according to XD-LAB.
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC)
|
CDA‑LREP |
hl7:telecom
|
TEL |
1 … * |
R |
A communication mean MUST be present according to XD-LAB. |
CDA‑LREP |
hl7:informationRecipient
|
|
0 … 1 |
|
If the person of the recipient is used, it MUST according to XD-LAB declare a name.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
|
CDA‑LREP |
hl7:receivedOrganization
|
|
0 … 1 |
|
If the organization of the recipient is used, it MUST according to XD-LAB declare
name, addr and telecom.
Contains 2.16.756.5.30.1.1.10.9.27 Organization Compilation with name, addr, telecom (DYNAMIC)
|
CDA‑LREP |
| |
Schematron assert |
role |
error
|
|
| |
test |
hl7:informationRecipient[not(@nullFlavor)] or hl7:receivedOrganization[not(@nullFlavor)] |
|
| |
Message |
Either the recipients person or organization MUST be declared. |
|
| Included |
0 … 1 |
|
from 2.16.756.5.30.1.1.10.2.61 Legal Authenticator (DYNAMIC)
|
hl7:legalAuthenticator
|
|
0 … 1 |
|
Legal authenticator. |
CDA‑LREP |
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑LREP |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.61 |
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑LREP |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.5 |
hl7:time
|
TS.CH.TZ |
1 … 1 |
R |
Date of the signature. |
CDA‑LREP |
hl7:signatureCode
|
CS |
1 … 1 |
R |
|
CDA‑LREP |
@code
|
cs |
1 … 1 |
F |
S |
@codeSystem
|
oid |
1 … 1 |
F |
2.16.840.1.113883.1.11.10282 |
@codeSystemName
|
st |
1 … 1 |
F |
ParticipationSignature |
@displayName
|
st |
1 … 1 |
F |
signed |
| |
CONF |
|
hl7:assignedEntity
|
|
1 … 1 |
R |
The GLN MUST be used to identify the legal authenticator (e.g., laboratory manager
or responsible physician). All persons and organizations, MUST according to XD-LAB
contain name, addr and telecom.
Contains 2.16.756.5.30.1.1.10.9.47 AssignedEntity Compilation for Laboratory (DYNAMIC)
|
CDA‑LREP |
hl7:authenticator
|
|
0 … * |
|
Contains 2.16.756.5.30.1.1.10.4.8 Laboratory Results Validator - participant Containment (DYNAMIC)
|
(CDA-V1) |
| Included |
0 … 1 |
|
from 2.16.756.5.30.1.1.10.2.16 Order Reference - inFulfillmentOf (DYNAMIC)
|
hl7:inFulfillmentOf
|
|
0 … 1 |
|
Reference to one or more orders which led to the creation of this CDA document. It
SHALL be declared, when the order reference is relevant for some reason.
|
CDA‑CH V2 |
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.16 |
hl7:order
|
|
1 … 1 |
R |
|
CDA‑CH V2 |
hl7:id
|
II |
1 … * |
R |
Order number. |
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
R |
Either the same GUID (order id) or the same OID (order issuing system) as the order
itself.
|
@extension
|
st |
0 … 1 |
|
Contains the order ID itself. The ID MUST be unique within the system that issued
the ID.
|
| Included |
0 … 1 |
|
from 2.16.756.5.30.1.1.10.2.46 Health Service - documentationOf (DYNAMIC)
|
hl7:documentationOf
|
|
0 … 1 |
|
Information about a health service describing the context of this CDA document. |
CDA‑CH V2 |
@typeCode
|
cs |
1 … 1 |
F |
DOC |
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.46 |
hl7:serviceEvent
|
|
1 … 1 |
R |
|
CDA‑CH V2 |
@classCode
|
cs |
1 … 1 |
F |
ACT |
@moodCode
|
cs |
1 … 1 |
F |
EVN |
hl7:id
|
II |
0 … * |
|
Health service identifiers such as case number ([ge]: Fallnummer; [fr]: Numéro de
cas), consultation id, episode id, etc.
|
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
R |
The OID of the system that issued the id. OIDs of code systems, which are published
in a public OID registry are REQUIRED. Others are NOT ALLOWED.
|
@extension
|
st |
0 … 1 |
|
The id itself. It MUST be unique within the issuing system. |
hl7:code
|
CE |
1 … 1 |
R |
As long as the eventCodeList for the Swiss EPR metadata is not defined yet by the
FDHA Ordinance on the Electronic Patient Record (EPRO-FDHA), the nullFlavor='NAV'
MUST be used in this template. Other codes MAY be declared as translation.
|
CDA‑CH V2 |
@nullFlavor
|
st |
1 … 1 |
F |
NAV |
@code
|
cs |
0 |
NP |
NP/not present |
@codeSystem
|
oid |
0 |
NP |
NP/not present |
@codeSystemName
|
st |
0 |
NP |
NP/not present |
@displayName
|
st |
0 |
NP |
NP/not present |
hl7:translation
|
|
0 … * |
|
A translation of the code to another coding system. |
CDA‑CH V2 |
@code
|
cs |
1 … 1 |
R |
|
@codeSystem
|
oid |
1 … 1 |
R |
|
@codeSystemName
|
st |
1 … 1 |
R |
|
@displayName
|
st |
1 … 1 |
R |
|
hl7:effectiveTime
|
IVL_TS.CH.TZ |
1 … 1 |
R |
Duration of the health service. |
CDA‑CH V2 |
hl7:low
|
TS.CH.TZ |
1 … 1 |
R |
Start of the health service. |
CDA‑CH V2 |
hl7:high
|
TS.CH.TZ |
1 … 1 |
R |
End of the health service. |
CDA‑CH V2 |
| Included |
0 … * |
|
from 2.16.756.5.30.1.1.10.9.31 Performer (DYNAMIC)
|
hl7:performer
|
|
0 … * |
|
Information about a healthcare provider who was the primary performer of the act. |
CDA‑CH V2 |
@typeCode
|
cs |
1 … 1 |
F |
PRF |
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.9.31 |
hl7:templateId
|
|
1 … 1 |
R |
|
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
1.3.6.1.4.1.19376.1.5.3.1.1.24.3.5 |
hl7:templateId
|
|
1 … 1 |
R |
|
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.10.12.323 |
hl7:time
|
IVL_TS.CH.TZ |
0 … 1 |
|
Duration of the performance. |
CDA‑CH V2 |
hl7:low
|
TS.CH.TZ |
1 … 1 |
R |
Start of the performance. |
CDA‑CH V2 |
hl7:high
|
TS.CH.TZ |
1 … 1 |
R |
End of the performance. |
CDA‑CH V2 |
hl7:assignedEntity
|
|
1 … 1 |
R |
Contains 2.16.756.5.30.1.1.10.9.32 Assigned Entity Compilation with id, name, addr, telecom, person and organization (DYNAMIC)
|
CDA‑CH V2 |
| Included |
0 … * |
|
from 2.16.756.5.30.1.1.10.2.28 Laboratory Performer - documentationOf (DYNAMIC)
|
hl7:documentationOf
|
|
0 … * |
|
|
IHE PalM TF3 Rev.10, 6.3.2.20 |
hl7:templateId
|
II |
1 … 1 |
M |
|
IHE PalM TF3 Rev.10, 6.3.2.20 |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.28 |
hl7:serviceEvent
|
|
1 … 1 |
R |
|
IHE PalM TF3 Rev.10, 6.3.2.20 |
hl7:effectiveTime
|
IVL_TS.CH.TZ |
0 … 1 |
|
Use of sub element documentationOf/serviceEvent/effectiveTime to document the time
boundaries of events in the document is appropriate.
|
IHE PalM TF3 Rev.10, 6.3.2.20 |
hl7:performer
|
|
0 … * |
|
Laboratory Performer template in the CDA header.
Contains 2.16.756.5.30.1.1.10.4.7 Laboratory Performer - performer Containment (DYNAMIC)
|
IHE PalM TF3 Rev.10, 6.3.2.20 |
| Included |
0 … * |
|
from 2.16.756.5.30.1.1.10.2.14 Insurance Card - participant (DYNAMIC)
|
hl7:participant
|
|
0 … * |
|
Information on a patient's insurance card. |
CDA‑CH V2 |
@typeCode
|
cs |
1 … 1 |
F |
HLD |
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.14 |
hl7:time
|
IVL_TS.CH.TZ |
1 … 1 |
R |
Validity period of the insurance card. |
CDA‑CH V2 |
hl7:low
|
TS.CH.TZ |
1 … 1 |
|
|
CDA‑CH V2 |
@nullFlavor
|
cs |
1 … 1 |
F |
NASK |
hl7:high
|
TS.CH.TZ |
1 … 1 |
R |
Expiration date of the insurance card. |
CDA‑CH V2 |
hl7:associatedEntity
|
|
1 … 1 |
R |
|
CDA‑CH V2 |
@classCode
|
cs |
1 … 1 |
F |
POLHOLD |
hl7:id
|
II |
1 … 1 |
R |
The insurance card's id. |
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.123.100.1.1.1 |
@extension
|
st |
1 … 1 |
R |
Number of the insurance card. |
hl7:associatedPerson
|
|
0 … 1 |
|
Family and given name on the insurance card.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
|
CDA‑CH V2 |
hl7:scopingOrganization
|
|
0 … 1 |
|
The insurance company which issued the insurance card.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC)
|
CDA‑CH V2 |
| Included |
0 … * |
|
from 2.16.756.5.30.1.1.10.2.15 Insurance - participant (DYNAMIC)
|
hl7:participant
|
|
0 … * |
|
Information on a patient's insurance. |
CDA‑CH V2 |
@typeCode
|
cs |
1 … 1 |
F |
COV |
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.15 |
hl7:time
|
IVL_TS.CH.TZ |
0 … 1 |
|
Validity period of the contract. |
CDA‑CH V2 |
hl7:low
|
TS.CH.TZ |
1 … 1 |
R |
Start of the contract. |
CDA‑CH V2 |
hl7:high
|
TS.CH.TZ |
1 … 1 |
R |
End of the contract. |
CDA‑CH V2 |
hl7:associatedEntity
|
|
1 … 1 |
R |
|
CDA‑CH V2 |
@classCode
|
cs |
1 … 1 |
F |
PAYOR |
hl7:id
|
II |
1 … 1 |
R |
The id of the contract ([ge]: Versichertennummer; [fr]: Numéro d'assuré). |
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
R |
The OID of the system that issued the id. OIDs of code systems, which are published
in a public OID registry are REQUIRED. Others are NOT ALLOWED.
|
@extension
|
st |
0 … 1 |
|
The id itself. It MUST be unique within the issuing system. |
hl7:code
|
CE |
1 … 1 |
R |
The underlying law for the contract. |
CDA‑CH V2 |
@nullFlavor
|
cs |
0 … 1 |
F |
NAV |
@code
|
cs |
0 … 1 |
|
832.10, 832.20, 221.229.1, 833.1, 831.20 |
@codeSystem
|
oid |
0 … 1 |
F |
2.16.756.5.30.2.1.1.11 |
@codeSystemName
|
st |
0 … 1 |
F |
ins-laws |
@displayName
|
st |
0 … 1 |
|
Federal Act on Health Insurance (HIA), Federal Act on Accident Insurance (AIA), Federal
Act on Insurance Policies (Insurance Policies Act, IPA), Federal Act on Military Insurance
(MilIA), Federal Act on Invalidity Insurance (InvIA)
|
| |
Schematron assert |
role |
error
|
|
| |
test |
(@nullFlavor='NAV' and not(@codeSystem or @codeSystemName or @code or @displayName))
or (@codeSystem='2.16.756.5.30.2.1.1.11' and @codeSystemName='ins-laws' and @code
and @displayName)
|
|
| |
Message |
Either a valid insurance law or nullFlavor="NAV" is REQUIRED. |
|
hl7:associatedPerson
|
|
0 … 1 |
|
Contact person at the insurance company.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC)
|
CDA‑CH V2 |
hl7:scopingOrganization
|
|
1 … 1 |
|
The insurance company.
Contains 2.16.756.5.30.1.1.10.9.26 Organization Compilation with GLN, name, addr and telecom (DYNAMIC)
|
CDA‑CH V2 |
| Included |
0 … * |
|
from 2.16.756.5.30.1.1.10.2.13 Document Replacement - relatedDocument (DYNAMIC)
|
hl7:relatedDocument
|
|
0 … * |
|
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.
|
CDA‑CH V2 |
@typeCode
|
cs |
1 … 1 |
F |
RPLC |
| |
Indicates that it is a relationship to another document that needs to be replaced. |
hl7:templateId
|
II |
1 … 1 |
M |
|
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
F |
2.16.756.5.30.1.1.10.2.13 |
hl7:parentDocument
|
|
1 … 1 |
R |
Relationship to the document that needs to be replaced. |
CDA‑CH V2 |
hl7:id
|
II |
1 … 1 |
M |
The id of the document to be replaced MUST be declared. |
CDA‑CH V2 |
@root
|
uid |
1 … 1 |
R |
The id (GUID) of the document to be replaced. |
@extension
|
st |
0 |
NP |
NP/not present |
hl7:setId
|
II |
1 … 1 |
M |
The setId of the document to be replaced MUST be declared. |
CDA‑CH V2 |
@extension
|
st |
0 |
NP |
NP/not present |
@root
|
uid |
1 … 1 |
R |
The setId (GUID) of the document to be replaced and MUST be identical with the content
of the setId of the current document.
|
| |
Schematron assert |
role |
error
|
|
| |
test |
(@root=/hl7:ClinicalDocument/hl7:setId/@root) and not(@extension) and not(/hl7:ClinicalDocument/hl7:setId/@extension) |
|
| |
Message |
ClinicalDocument/setId: MUST be identical to the one of the replaced document |
|
hl7:versionNumber
|
INT |
1 … 1 |
M |
The version number of the document to be replaced. |
CDA‑CH V2 |
| |
Schematron assert |
role |
error
|
|
| |
test |
/hl7:ClinicalDocument/hl7:versionNumber/@value > @value |
|
| |
Message |
ClinicalDocument/versionNumber: MUST be higher than the one of the replaced document |
|
hl7:component
|
|
1 … 1 |
R |
|
(CDA-V1) |
hl7:structuredBody
|
|
1 … 1 |
R |
|
(CDA-V1) |
hl7:component
|
|
1 … * |
M |
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.
Contains 2.16.756.5.30.1.1.10.3.3 Laboratory Speciality Section - coded (DYNAMIC)
|
(CDA-V1) |
hl7:component
|
|
0 … 1 |
|
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.
Contains 2.16.756.5.30.1.1.10.3.4 Vital Signs Section - coded (DYNAMIC)
|
(CDA-V1) |
hl7:component
|
|
0 … 1 |
|
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.
Contains 2.16.756.5.30.1.1.10.3.46 Other Relevant Observations Section - coded (DYNAMIC)
|
(CDA-V1) |
hl7:component
|
|
0 … 1 |
|
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.
Contains 2.16.756.5.30.1.1.10.3.53 Current Pregnancy Section - coded (DYNAMIC)
|
(CDA-V1) |
hl7:component
|
|
0 … 1 |
|
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.
Contains 2.16.756.5.30.1.1.10.3.45 Original Representation Section - coded (DYNAMIC)
|
(CDA-V1) |
| |
Schematron assert |
role |
 warning
|
|
| |
test |
not(//hl7:id[@root='2.16.756.5.30.1.127.3.10.3']) |
|
| |
Message |
This CDA-CH-LREP document contains a Swiss EPR-SPID. Please make sure, that this fits
the legal base. |
|
| |
Schematron report |
role |
warning
|
|
| |
test |
//hl7:id[@root=('2.16.756.5.31', '2.16.756.5.32')]/parent::hl7:patientRole |
|
| |
Message |
This CDA-CH-LREP document contains a Swiss Social Security number as patient identifier.
Please make sure, that this fits the legal base. |
|
| |
Schematron assert |
role |
error
|
|
| |
test |
not(//hl7:id[@root=('2.16.756.5.30.1.127.3.10.3', '2.16.756.5.31', '2.16.756.5.32')]/../..[not(hl7:patientRole)]) |
|
| |
Message |
Swiss EPR-SPID and Social Security numbers are not allowed in CDA-CH-LREP documents
for other objects than the patient. |
|
Template General Laboratory Report
Document Realm (2017)
Transaction