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active Template  Laboratory Report Item Section - coded

Id 2.16.756.5.30.1.1.10.3.76 Effective Date 2020‑06‑26
Status active Active Version Label 2020
Name cdachlrep_section_LaboratoryReportItemCoded Display Name Laboratory Report Item Section - coded
Description

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: Use of sub-sections (Laboratory Report Item Sections):

With this option, the results of the examination MUST be documented in the subsections, and the main section (Laboratory Specialty Section) MUST NOT contain any text OR entry elements.

Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.3.76
Label IHE PalM TF3 Rev.10, 6.3.3.2
Classification CDA Section Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 2 templates, Uses 1 template
Used by as Name Version
cdachlrep-transaction-2 Transaction pending CDA-CH-LREP - General Laboratory Report (2018) 2018‑03‑06 18:38:46
2.16.756.5.30.1.1.10.3.77 Containment active Laboratory Speciality Section - coded (2020) 2020‑06‑26
2.16.756.5.30.1.1.10.1.10 link active General Laboratory Report (2020) 2020‑06‑26
Uses as Name Version
2.16.756.5.30.1.1.10.4.118 Containment active Laboratory Report Data Processing Entry (2020) DYNAMIC
Relationship Specialization: template 2.16.756.5.30.1.1.10.3.5 Laboratory Report Item Section - coded (2017‑06‑21)
ref
ch-palm-

Specialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-

Specialization: template 1.3.6.1.4.1.19376.1.3.3.2.2 Laboratory Report Item Section (2008‑08‑08)
ref
XDLAB-
Example
Example
<section>
  <templateId root="1.3.6.1.4.1.19376.1.3.3.2.2"/>  <templateId root="2.16.756.5.30.1.1.10.3.5"/>  <code displayName="Cell marker studies" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1" code="18718-7"/>  <title>Laborbefund - Molekularbiologie</title>  <text/>  <entry typeCode="DRIV">
    <!-- template 2.16.756.5.30.1.1.10.4.4 'Laboratory Report Data Processing Entry' -->
  </entry></section>
Item DT Card Conf Description Label
hl7:section
 		IHE PalM TF3 Rev.10, 6.3.3.2
hl7:templateId
 		II 1 … 1 M IHE PalM TF3 Rev.10, 6.3.3.2
@root
 		uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.3.2.2
hl7:templateId
 		II 1 … 1 M IHE PalM TF3 Rev.10, 6.3.3.2
@root
 		uid 1 … 1 F 2.16.756.5.30.1.1.10.3.5
hl7:templateId
 		II 1 … 1 M IHE PalM TF3 Rev.10, 6.3.3.2
@root
 		uid 1 … 1 F 2.16.756.5.30.1.1.10.3.76
hl7:id
 		II 0 … 1 An ID for this section MAY be filled for traceability. IHE PalM TF3 Rev.10, 6.3.3.2
@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
 		CE 1 … 1 R This declares the laboratory discipline of the section. IHE PalM TF3 Rev.10, 6.3.3.2
@code
 		cs 1 … 1 R The code MUST be declared and 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
 		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 M

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]: Immunohématologie
[it]: Immunoematologia
18718-7 [ge]: Molekularbiologie
[fr]: Biologie moléculaire
[it]: Biologia molecolare
18719-5 [ge]: Chemie
[fr]: Chimie
[it]: Chimica
18720-3 [ge]: Gerinnung
[fr]: Coagulation
[it]: Coagulazione
18721-1 [ge]: Medikamente
[fr]: Médicaments
[it]: Medicamenti
18722-9 [ge]: Fertilität
[fr]: Fertilité
[it]: Fertilità
18723-7 [ge]: Hämatologie
[fr]: Hématologie
[it]: Ematologia
18724-5 [ge]: HLA
[fr]: HLA
[it]: HLA
18725-2 [ge]: Mikrobiologie
[fr]: Microbiologie
[it]: Microbiologia
18727-8 [ge]: Serologie
[fr]: Sérologie
[it]: Sierologia
18728-6 [ge]: Toxikologie
[fr]: Toxicologie
[it]: Tessicologia
18729-4 [ge]: Urin Untersuchungen
[fr]: Analyses dans l'urine
[it]: Analisi nelle urine
18767-4 [ge]: Blutgase
[fr]: Gazométrie
[it]: Gasometria
18768-2 [ge]: Differenzialblutbild
[fr]: Répartition leucocytaire
[it]: Differenziazione leucocitaria
18769-0 [ge]: Antibiogramme
[fr]: Antibiogramme
[it]: Antibiogramma
26435-8 [ge]: Molekulare Pathologie
[fr]: Pathologie moleculaire
[it]: Patologia moleculare
26436-6 [ge]: Laboruntersuchungen
[fr]: Études de laboratoire
[it]: Esami di laboratorio
26437-4 [ge]: Stimulationen
[fr]: Stimulation
[it]: Stimolazione
26438-2 [ge]: Zytologie
[fr]: Cytologie
[it]: Citologia
IHE PalM TF3 Rev.10, 6.3.3.2
  Example
German
<title>Laborbefund - Immunhämatologie</title>
  Example
English
<title>Laboratory Specialty - Blood Bank Studies</title>
  Variable let Name languageCode  
  Value substring(/hl7:ClinicalDocument/hl7:languageCode/@code,1,2)  
  Schematron assert role red error  
  test not($languageCode='en') or starts-with(text(),'Laboratory report')  
  Message The English title must start with 'Laboratory report'  
  Schematron assert role red error  
  test not($languageCode='de') or starts-with(text(),'Laborbefund')  
  Message The German title must start with 'Laborbefund'  
  Schematron assert role red error  
  test not($languageCode='fr') or starts-with(text(),'Rapport de laboratoire')  
  Message The French title must start with 'Rapport de laboratoire'  
  Schematron assert role red error  
  test not($languageCode='it') or starts-with(text(),'Rapporto di laboratorio')  
  Message The Italian title must start with 'Rapporto di laboratorio'  
hl7:text
 		SD.TEXT 1 … 1 R The laboratory results MUST be automatically generated readable for humans in the text element of the section from the information in the Laboratory Data Processing Entry. IHE PalM TF3 Rev.10, 6.3.3.2
hl7:entry
 		1 … 1 R The narrative text in the text element of the section MUST be generated automatically from the information in this entry.
Contains 2.16.756.5.30.1.1.10.4.118 Laboratory Report Data Processing Entry (DYNAMIC) 		IHE PalM TF3 Rev.10, 6.3.3.2
@typeCode
 		cs 1 … 1 F DRIV