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active Template  Laboratory Speciality Section - coded

Id 2.16.756.5.30.1.1.10.3.77 Effective Date 2020‑06‑26
Status active Active Version Label 2020
Name cdachlrep_section_LaboratorySpecialtyCoded Display Name Laboratory Speciality Section - coded
Description
Chapter (CDA Body Section) with laboratory results according to Sharing Laboratory Reports (XD-LAB) Content Module, IHE PaLM Technical Framework Revision 8.0 - June 21, 2017.
Each Laboratory Specialty Section contains laboratory tests of a particular discipline (e.g., microbiology or serology).
The Laboratory Specialty Section uses LOINC codes to define the appropriate discipline. Laboratory Specialty Sections MUST NOT be nested.
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: Laboratory Report Item Section
    With this option, this Laboratory Specialty Section SHALL contain NEITHER a top level text NOR entry elements. Each Report Item is contained in a corresponding Laboratory Report Item Section which contains the Lab Report Data Processing Entry.
  • Choice 2: Text and Entry
    With this option, the examination results MUST be documented in the text element of the section and the corresponding entry element (Laboratory Data Processing Entry).
    The human-readable text MUST be generated automatically from the entry and its sub-elements.
    For this purpose the presentation options according to the CDA Narrative Block schema (NarrativeBlock.xsd) may be used: tables, lists, paragraphs, hyperlinks, footnotes, references to attached or embedded multimedia objects.
If a document contains multiple Laboratory Specialty Sections, Choice 1 or Choice 2 can be selected for each individual chapter.
Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.3.77
Label IHE PalM TF3 Rev.10, 6.3.3.1
Classification CDA Section Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 1 template, Uses 2 templates
Used by as Name Version
cdachlrep-transaction-2 Transaction pending CDA-CH-LREP - General Laboratory Report (2018) 2018‑03‑06 18:38:46
2.16.756.5.30.1.1.10.1.10 Containment active General Laboratory Report (2020) 2020‑06‑26
Uses as Name Version
2.16.756.5.30.1.1.10.3.76 Containment active Laboratory Report Item Section - coded (2020) DYNAMIC
2.16.756.5.30.1.1.10.4.118 Containment active Laboratory Report Data Processing Entry (2020) DYNAMIC
Relationship Specialization: template 2.16.756.5.30.1.1.10.3.3 (2017‑06‑21)
ref
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Specialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-

Specialization: template 1.3.6.1.4.1.19376.1.3.3.2.1 Laboratory Specialty Section (2008‑08‑08)
ref
XDLAB-
Example
Specialty Section that holds a leaf section and Leaf Section that holds one Report Item
<section classCode="DOCSECT">
  <templateId root="2.16.756.5.30.1.1.10.3.3"/>  <templateId root="1.3.6.1.4.1.19376.1.3.3.2.1"/>  <code code="18723-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HEMATOLOGY STUDIES"/>  <title>Laborbefund - Hämatologie</title>  <component>
    <section>
      <templateId root="1.3.6.1.4.1.19376.1.3.3.2.2"/>      <!-- Leaf Section that holds one Report Item -->
    </section>  </component></section>
Example
Specialty Section that holds Report Items directly as a Laboratory Report Data Processing Entry
<section classCode="DOCSECT">
  <templateId root="2.16.756.5.30.1.1.10.3.3"/>  <templateId root="1.3.6.1.4.1.19376.1.3.3.2.1"/>  <code code="18719-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="CHEMISTRY STUDIES"/>  <title>Laborbefund - Chemie</title>  <text>narrative text</text>  <entry typeCode="DRIV">
    <templateId root="1.3.6.1.4.1.19376.1.3"/>    <act classCode="ACT" moodCode="EVN"> ... </act>  </entry></section>
Item DT Card Conf Description Label
hl7:section
 		IHE PalM TF3 Rev.10, 6.3.3.1
hl7:templateId
 		II 1 … 1 M IHE PalM TF3 Rev.10, 6.3.3.1
@root
 		uid 1 … 1 F 2.16.756.5.30.1.1.10.3.3
hl7:templateId
 		II 1 … 1 M IHE PalM TF3 Rev.10, 6.3.3.1
@root
 		uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.3.2.1
hl7:templateId
 		II 1 … 1 M IHE PalM TF3 Rev.10, 6.3.3.1
@root
 		uid 1 … 1 F 2.16.756.5.30.1.1.10.3.77
hl7:id
 		II 0 … 1 An ID for this section MAY be filled for traceability. IHE PalM TF3 Rev.10, 6.3.3.1
@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 M This declares the laboratory discipline of the section. IHE PalM TF3 Rev.10, 6.3.3.1
@code
 		st 1 … 1 R
@codeSystem
 		oid 1 … 1 F 2.16.840.1.113883.6.1
@codeSystemName
 		st 1 … 1 F LOINC
@displayName
 		st 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 R

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, 6.3.3.1
  Example
Deutsch
<title>Laborbefund - Immunhämatologie</title>
  Example
Englisch
<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 0 … 1 R The narrative text for this section. IHE PalM TF3 Rev.10, 6.3.3.1
Choice 1 … * Elements to choose from:
hl7:component
 		0 … * C Contains 2.16.756.5.30.1.1.10.3.76 Laboratory Report Item Section - coded (DYNAMIC) IHE PalM TF3 Rev.10, 6.3.3.1
hl7:entry
 		0 … * C 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, 6.3.3.1
@typeCode
 		cs 1 … 1 F DRIV
  Schematron assert role red error  
  test (hl7:component and not(hl7:text or hl7:entry)) or (not(hl7:component) and hl7:text and hl7:entry)  
  Message 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.