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retired Template  Laborbefund Transplantationsprozesss

Id 2.16.756.5.30.1.127.10.1.3 Effective Date 2016‑07‑02
Other versions this id:
Status retired Retired Version Label
Name cdachlrtp Display Name Laborbefund Transplantationsprozesss
Description
(de-CH) Laborbefund im Transplantationsprozesss
Context Pathname /
Classification CDA Document Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 11 templates
Uses as Name Version
2.16.756.5.30.1.127.10.2.29 Include draft CDA recordTarget (lrtp) DYNAMIC
2.16.756.5.30.1.1.10.2.7 Include active Data Enterer (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.3 Include active Custodian (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.4 Include active Recipient - informationRecipient (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.5 Include active Legal Authenticator (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.6 Include active Authenticator (2017) DYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.6 Include active Ordering Provider (2017) DYNAMIC
2.16.756.5.30.1.1.10.2.16 Include active Order Reference - inFulfillmentOf (2017) DYNAMIC
2.16.756.5.30.1.127.10.3.11 Containment draft Blutgruppe Section DYNAMIC
2.16.756.5.30.1.1.10.3.4 Containment pending Vital Signs Section - coded (2016) DYNAMIC
2.16.756.5.30.1.127.10.3.12 Containment draft Laborbefund Section (lrtp) DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.12.2 (2005‑09‑07)
Example
Example
<ClinicalDocument>
  <realmCode code="CHE"/>  <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>  <templateId root="1.3.6.1.4.1.19376.1.3.3"/>  <templateId root="2.16.756.5.30.1.1.1.1"/>  <templateId root="2.16.756.5.30.1.1.1.1.3.4.1"/>  <id extension="A68AF3DB-5A1D-4C6C-85FA-2816E723DEF4" root="2.16.756.5.30.1.1.1.1.3.4.1"/>  <code code="11502-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="LABORATORY REPORT.TOTAL"/>  <title>Laborbefund im Transplantationsprozess</title>  <effectiveTime value="20140116"/>  <confidentialityCode code="R" codeSystem="2.16.840.1.113883.5.25"/>  <languageCode code="de-CH"/>  <setId extension="CD3AFF99-8956-44EF-A882-B160AAAFBF2A" root="2.16.756.5.30.1.1.1.1.3.4.1"/>  <versionNumber value="1"/>  <recordTarget>
    <!-- .. -->
  </recordTarget>  <author>
    <!-- .. -->
  </author>  <custodian>
    <!-- .. -->
  </custodian>  <informationRecipient typeCode="PRCP">
    <!-- .. -->
  </informationRecipient>  <documentationOf>
    <!-- .. -->
  </documentationOf>  <component>
    <structuredBody>
      <!-- .. -->
    </structuredBody>  </component></ClinicalDocument>
Item DT Card Conf Description Label
hl7:ClinicalDocument
 (cdadotsrtp)
Included from 2.16.756.5.30.1.1.10.9.1 (DYNAMIC)
  Include
alert Error: Cannot find template "2.16.756.5.30.1.1.10.9.1" (DYNAMIC)
Included from 2.16.756.5.30.1.1.10.9.2 (DYNAMIC)
  Include
alert Error: Cannot find template "2.16.756.5.30.1.1.10.9.2" (DYNAMIC)
hl7:templateId
 II 1 … 1 M (cdadotsrtp)
@root
 1 … 1 F 1.3.6.1.4.1.19376.1.3.3
hl7:templateId
 II 1 … 1 M (cdadotsrtp)
@root
 1 … 1 F 2.16.756.5.30.1.1.1.1
hl7:templateId
 II 1 … 1 M (cdadotsrtp)
@root
 1 … 1 F 2.16.756.5.30.1.1.1.1.3.4.1
Included from 2.16.756.5.30.1.1.10.9.3 (DYNAMIC)
  Include
alert Error: Cannot find template "2.16.756.5.30.1.1.10.9.3" (DYNAMIC)
hl7:code
 CE 1 … 1 R CDA‑dotsCODE
@code
 CONF 0 … 1 F 11502-2
@codeSystem
 0 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
@codeSystemName
 0 … 1 F LOINC
@displayName
 0 … 1 F LABORATORY REPORT.TOTAL
  Example <code code="11502-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="LABORATORY REPORT.TOTAL"/>
Included from 2.16.756.5.30.1.1.10.9.4 (DYNAMIC)
  Include
alert Error: Cannot find template "2.16.756.5.30.1.1.10.9.4" (DYNAMIC)
hl7:effectiveTime
 TS.CH.TZ 1 … 1 R (cdadotsrtp)
hl7:confidentialityCode
 CE 1 … 1 R (cdadotsrtp)
@code
 CONF 0 … 1 F R
@codeSystem
 0 … 1 F 2.16.840.1.113883.5.25 (Confidentiality)
Included from 2.16.756.5.30.1.1.10.9.5 (DYNAMIC)
  Include
alert Error: Cannot find template "2.16.756.5.30.1.1.10.9.5" (DYNAMIC)
Included from 2.16.756.5.30.1.1.10.9.7 (DYNAMIC)
  Include
alert Error: Cannot find template "2.16.756.5.30.1.1.10.9.7" (DYNAMIC)
Included from 2.16.756.5.30.1.127.10.2.29 CDA recordTarget (lrtp) (DYNAMIC)
hl7:recordTarget
 1 … 1 R (cdadotsrtp)
@typeCode
 cs 0 … 1 F RCT
@contextControlCode
 cs 0 … 1 F OP
hl7:patientRole
 1 … 1 R (cdadotsrtp)
@classCode
 cs 0 … 1 F PAT
hl7:id
 II 0 … * R (cdadotsrtp)
treeblank treeblank treeblank where [not(@root='2.16.756.5.30.1.129.1.1.1')]
hl7:id
 II 1 … 1 M (cdadotsrtp)
treeblank treeblank treeblank where [@root='2.16.756.5.30.1.129.1.1.1']
@root
 1 … 1 F 2.16.756.5.30.1.129.1.1.1
@extension
 1 … 1 R
(de-CH) SOAS-ID
hl7:patient
 0 … 1 (cdadotsrtp)
@classCode
 cs 0 … 1 F PSN
@determinerCode
 cs 0 … 1 F INSTANCE
hl7:name
 PN 1 … 1 R (cdadotsrtp)
hl7:administrativeGenderCode
 CE 1 … 1 R (cdadotsrtp)
  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 (cdadotsrtp)
Included from 2.16.756.5.30.1.1.10.2.2 (DYNAMIC)
  Include
alert Error: Cannot find template "2.16.756.5.30.1.1.10.2.2" (DYNAMIC)
Included 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 from 2.16.756.5.30.1.1.10.2.3 Custodian (DYNAMIC)
hl7:custodian
 1 … 1 R The organization in whose name this CDA document has been created (corresponds to the sender of a letter). CDA‑CH V2
hl7:templateId
 II 1 … 1 M CDA‑CH V2
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.2.3
hl7:assignedCustodian
 1 … 1 R CDA‑CH V2
hl7:representedCustodianOrganization
 1 … 1 R CDA‑CH V2
hl7:id
 II 1 … * M The custodian's id. 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   Contains the ID itself. The ID MUST be unique within the system that issued the ID.
hl7:name
 ON 1 … 1 R The custodian's name. CDA‑CH V2
hl7:telecom
 TEL 0 … * The custodian's means of communication (phone, eMail, ...). CDA‑CH V2
hl7:addr
 AD 0 … * The custodian's address(es).
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC) 		CDA‑CH V2
Included from 2.16.756.5.30.1.1.10.2.4 Recipient - informationRecipient (DYNAMIC)
hl7:informationRecipient
 1 … * R A recipient of this CDA document (corresponds to the addressee of a letter - person or organization).

Recipient types:
  • The main recipient of the document is indicated by typeCode 'PRCP' (primary recipient).
    Note: Since it makes no sense to create a CDA document without doing it for someone, in Switzerland at least one recipient MUST be declared. If the document is created for the user's own needs, the user itself or its organization will be the primary recipient.

  • Other recipients (copy to; Cc) are indicated with typeCode, TRC '(secondary recipient).
 CDA‑CH V2
@typeCode
 cs 0 … 1   The main recipient of the document is indicated by typeCode 'PRCP' (primary recipient). This is the default value used when the attribute is not present.
Other recipients (copy to; Cc) are indicated with typeCode, TRC '(secondary recipient).
Note: Since it makes no sense to create a CDA document without doing it for someone, in Switzerland at least one recipient MUST be declared. If the document is created for the user's own needs, the user itself or its organization will be the primary recipient.
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19366 x_InformationRecipient (DYNAMIC)
hl7:templateId
 II 1 … 1 M CDA‑CH V2
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.2.4
hl7:intendedRecipient
 1 … 1 R CDA‑CH V2
hl7:id
 II 0 … * R The recipient's identification(s). 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   Contains the ID itself. The ID MUST be unique within the system that issued the ID.
hl7:addr
 AD 0 … * The recipient's address(es).
Contains 2.16.756.5.30.1.1.10.9.35 Address Information Compilation - eCH-0010 (DYNAMIC) 		CDA‑CH V2
hl7:telecom
 TEL 0 … * The recipient's means of communication (phone, eMail, ...). CDA‑CH V2
hl7:informationRecipient
 0 … 1 The addressee person.
Contains 2.16.756.5.30.1.1.10.9.34 Person Name Information Compilation - eCH-0011 (DYNAMIC) 		CDA‑CH V2
hl7:receivedOrganization
 0 … 1 The addressee organization.
Contains 2.16.756.5.30.1.1.10.9.24 Organization Compilation with name (DYNAMIC) 		CDA‑CH V2
Included from 2.16.756.5.30.1.1.10.2.5 Legal Authenticator (DYNAMIC)
hl7:legalAuthenticator
 0 … 1 Information about the legal authenticator of a CDA document. A legal authenticator MUST be a person. CDA‑CH V2
hl7:templateId
 II 1 … 1 M CDA‑CH V2
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.2.5
hl7:time
 TS.CH.TZ 1 … 1 R Timestamp of the signature. CDA‑CH V2
hl7:signatureCode
 CS 1 … 1 R CDA‑CH V2
@code
 cs 1 … 1 F S
@codeSystem
 oid 0 NP NP/not present
@codeSystemName
 st 0 NP NP/not present
@displayName
 st 0 NP NP/not present
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)
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 from 2.16.756.5.30.1.1.10.2.6 Authenticator (DYNAMIC)
hl7:authenticator
 0 … * Information about an authenticator of a CDA document. An authenticator MUST be a person. CDA‑CH V2
hl7:templateId
 II 1 … 1 M CDA‑CH V2
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.2.6
hl7:time
 TS.CH.TZ 1 … 1 R Timestamp of the signature. CDA‑CH V2
hl7:signatureCode
 CS 1 … 1 R CDA‑CH V2
@code
 cs 1 … 1 F S
@codeSystem
 oid 0 NP NP/not present
@codeSystemName
 st 0 NP NP/not present
@displayName
 st 0 NP NP/not present
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)
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 from 1.3.6.1.4.1.19376.1.3.3.1.6 Ordering Provider (DYNAMIC)
hl7:participant
 Referral Ordering Physician (cdadotsrtp)
@typeCode
 cs 1 … 1 F REF
hl7:templateId
 II 1 … 1 (cdadotsrtp)
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.3.1.6
hl7:time
 IVL_TS 1 … 1 R This element represents the date and time the order was placed. Time MAY be present. (cdadotsrtp)
hl7:associatedEntity
 1 … 1 (cdadotsrtp)
hl7:addr
 AD 1 … * R The address of this person (referral ordering physician) SHALL be present. (cdadotsrtp)
hl7:telecom
 TEL 1 … * R The telecom of this person (referral ordering physician) SHALL be present. (cdadotsrtp)
  Schematron assert role red error  
  test not(hl7:assignedPerson) or hl7:assignedPerson/hl7:name  
  Message The <name> sub-element SHALL be present when <assignedPerson> present.  
hl7:associatedPerson
 0 … 1 R (cdadotsrtp)
hl7:scopingOrganization
 0 … 1 (cdadotsrtp)
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.
hl7:documentationOf
 1 … 1 R
(de-CH) Die Fallunterscheidung der untersuchten Person resp. der Geltungsbereich des Befundes (Leichenspender, Lebendspender, Organempfänger) wird im CDA Header mit dem documentationOf Element dokumentiert.
(cdadotsrtp)
  Example <documentationOf>
  <serviceEvent>
    <code code="RECIP" displayName="Recipient" codeSystem="2.16.756.5.30.1.129.1.1.4"/>  </serviceEvent></documentationOf>
  Example <documentationOf>
  <serviceEvent>
    <code code="DDON" displayName="Deceased donor" codeSystem="2.16.756.5.30.1.129.1.1.4"/>  </serviceEvent></documentationOf>
hl7:serviceEvent
 1 … 1 R (cdadotsrtp)
hl7:code
 CE 1 … 1 M (cdadotsrtp)
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.127.11.20 Geltungsbereich des Befundes (DYNAMIC)
Included from 2.16.756.5.30.1.1.10.2.9 (DYNAMIC)
(de-CH)
Für die Korrektur falsch übermittelter Werte muss ein neues Dokument erstellt werden, welches das frühere Dokument ersetzt. Beim Verarbeiten des neuen Dokuments werden sämtliche Werte aus dem zu ersetzenden Dokument als veraltet interpretiert (gelöscht oder als gelöscht resp. als veraltet markiert). Alle Werte im neuen Dokument werden als gültig markiert. Werte, die nur im alten Dokument enthalten waren sind gelöscht. Werte, die in beiden Dokumenten vorhanden sind werden mit dem Inhalt des neuen Dokuments überschrieben. Werte, die nur im neuen Dokument enthalten sind werden neu erfasst.
Die Verbindung zum zu ersetzenden Dokument MUSS lauten:
ClinicalDocument/relatedDocument/@typeCode="RPLC"
parentDocument/id: ID des referenzierten Dokuments (ClinicalDocument/id)
ClinicalDocument/setId: MUSS identisch sein mit dem zu ersetzenden Dokument.
ClinicalDocument/versionNumber/@value: Muss gegenüber dem zu ersetzenden Dokument um 1 erhöht werden.
  Include
alert Error: Cannot find template "2.16.756.5.30.1.1.10.2.9" (DYNAMIC)
Included from 2.16.756.5.30.1.1.10.2.12 (DYNAMIC)
  Include
alert Error: Cannot find template "2.16.756.5.30.1.1.10.2.12" (DYNAMIC)
Included from 2.16.756.5.30.1.1.10.2.10 (DYNAMIC)
  Include
alert Error: Cannot find template "2.16.756.5.30.1.1.10.2.10" (DYNAMIC)
hl7:component
 1 … 1 R (cdadotsrtp)
@contextConductionInd
 bl 0 … 1 F true
hl7:structuredBody
 1 … 1 R (cdadotsrtp)
hl7:component
 0 … 1 R
(de-CH) Blutgruppe

Contains 2.16.756.5.30.1.127.10.3.11 Blutgruppe Section (DYNAMIC) 		(cdadotsrtp)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '2.16.756.5.30.1.127.10.3.11'] and hl7:templateId [@root = '2.16.756.5.30.1.1.1.1.3.4.1'] [@extension = 'CDA-CH.LRTP.Body.StudiesSummaryL2']]]
@contextConductionInd
 bl 0 … 1 F true
hl7:component
 0 … 1 R
(de-CH) Vitalzeichen

Contains 2.16.756.5.30.1.1.10.3.4 Vital Signs Section - coded (DYNAMIC) 		(cdadotsrtp)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '2.16.756.5.30.1.1.10.3.4'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.3.25'] and hl7:templateId [@root = '2.16.840.1.113883.10.20.1.16']]]
@contextConductionInd
 bl 0 … 1 F true
hl7:component
 0 … 1 R
(de-CH) Laborbefund

Contains 2.16.756.5.30.1.127.10.3.12 Laborbefund Section (lrtp) (DYNAMIC) 		(cdadotsrtp)
treeblank treeblank treeblank where [hl7:section [hl7:templateId [@root = '2.16.756.5.30.1.127.10.3.12'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.3.3.2.1']]]
@contextConductionInd
 bl 0 … 1 F true
  Schematron assert role red error  
  test count(hl7:component/hl7:section)>0  
  Message Mindestens eine Section muss im CDA-CH-LRTP Dokument vorhanden sein