Template  XeH Laboratory Result Report

Human (patient): The document reports laboratory observations produced on specimens collected exclusively from the patient.

All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.

Non-Human Subject: The document reports laboratory observations produced on specimens collected from a non-human material (e.g., water, milk, etc.) or living subject (e.g., animal).

Human (patient) paired with Non-Human Subject: The document reports laboratory observations produced on a non-human specimen with a relationship to a human patient (e.g., peanut butter eaten by a patient, a ferret that bit a patient).

The laboratory report can be authored by a software system or by a person or by both.
The author/time element carries the date&time the laboratory report was produced.

It represents the organization that is in charge of maintaining the laboratory report.

The informationRecipient/intendedRecipient element can be multiple. It introduces an intended recipient of the laboratory report, other than the Ordering Provider (described as a referrer participant).
These elements carry the list of the originally intended recipients of the laboratory report, i.e., those who were known at the time the report was created and published for sharing.

This element carries the person who has legally authenticated the report, and the organization represented by this person.
The sub-element time carries the date&time this legal authentication took place. The sub-element signatureCode carries the “signed” (S) status

If this entity happens also to be one of the validators of the laboratory results in the report, it SHALL also be documented as a validator.

When present it represents the clinical expert who performed the clinical validation (see the entries “validator” and “clinical expert” in the glossary in LAB TF-1:1.11) of the report or of a subset of its results, also called the validator.

There MAY be more than one validator of the report. All the validators SHALL appear in the report header as authenticator elements AND, in the case of multiple validators, each individual validator SHALL be associated with the particular sections of the report he or she validated. In this case, the validator of a section SHALL also appear in the entry this section is derived from.

In particular, when the ordering provider of the order (or group of orders) fulfilled by this laboratory report is present in the CDA, it SHALL be documented as a participant with the attribute typeCode valued “REF” (referrer).

It represents the Placer Order or the Placer Group that was fulfilled, the id of which is carried by inFulfillmentOf/order/id.

A reference to a ParentDocument representing the source of a document revision, addenda, or transformation.

It describes the encounter during which the reported lab observations were ordered. When present the encounter :

• is identified with an id element: encompassingEncounter/id
• have an effective time that represents the time interval (possibly still running, e.g., an inpatient current stay) of the encounter or a point in time at which the encounter took place (e.g., an outpatient consultation): encompassingEncounter/ effectiveTime

The encounter can provide any number of encounter participants (encompassingEncounter/encounterParticipant/assignedEntity).
The encounter could precise the patient location during this encounter. This is the healthcare facility in which the patient was located when the reported lab test observations were ordered: encompassingEncounter/location/healthCareFacility. This healthcare facility can be represented as a physical place (e.g., room, floor, building, office) or as an organization (e.g., service, department, team) or both: healthCareFacility/location, healthCareFacility/serviceProviderOrganization.