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draft Template  XeH Lab DocumentationOf

Id 2.16.840.1.113883.2.51.10.47 Effective Date 2021‑11‑29 17:16:55
Status draft Draft Version Label 2017
Name XeHLabDocumentationOf Display Name XeH Lab DocumentationOf
Description

Content Modules for CDA Header (Level 1): Laboratory Performer template in the CDA header (ClinicalDocument/documentationOf/serviceEvent)

ClinicalDocument/documentationOf(s) MAY be present. The documentationOf/serviceEvent represents the main Act being documented, that is an act of reporting Result Event(s) produced by a laboratory.

Use of sub element documentationOf/serviceEvent/effectiveTime to document the time boundaries of events in the document is appropriate.

This laboratory report content module adds the optional sub element documentationOf/serviceEvent/statusCode to enable the sharing of non-final reports. A report is considered as non-final (e.g., a preliminary report) if and only if it documents an Act, which is still in the status “active” (i.e., serviceEvent/statusCode@code=”active”).

The statusCode sub element is an extension to the CDA R2 schema. This sub-element is optional. When it is not there, the documented Act is assumed to be completed and the report is assumed to be a final report.

Classification CDA Header Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 1 template
Used by as Name Version
2.16.840.1.113883.2.51.10.33 Include draft XeH Laboratory Result Report (0.1) 2021‑10‑01 11:41:22
Uses as Name Version
1.3.6.1.4.1.19376.1.3.3.1.7 Containment active Laboratory Performer (2017) DYNAMIC
Relationship Specialization: template 1.3.6.1.4.1.19376.1.3.10.9.15 XD-LAB DocumentationOf (2016‑07‑05)
ref
XDLAB-

Specialization: template 2.16.840.1.113883.10.12.110 CDA documentationOf (2005‑09‑07)
ref
ad1bbr-
Item DT Card Conf Description Label
hl7:documentationOf
 		1 … * R There SHALL be exactly one documentationOf/serviceEvent element present for each Laboratory Specialty Section in the CDA Body of the report.

The code of the serviceEvent SHALL be exactly the same as the code of the referred Laboratory Specialty Section (see below) 		(XeHdotsnOf)
hl7:serviceEvent
 		1 … 1 R (XeHdotsnOf)
hl7:code
 		CE.IPS 1 … 1 R This code SHALL be set to exact the same code, as the code of the Laboratory Specialty section this serviceEvent element refers to (XeHdotsnOf)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.2.51.13.1.2 XeH Lab Study Types (DYNAMIC)
hl7:effectiveTime
 		IVL_TS 0 … 1

Use of sub element documentationOf/serviceEvent/effectiveTime to document the time boundaries of events in the document is appropriate.

(XeHdotsnOf)
lab:statusCode
 		CS 0 … 1

This Laboratory Report Content Module can express both final and non-final reports. To distinguish between the two, the statusCode element has been added to the documentationOf/serviceEvent element. A non-final report is a report documenting a serviceEvent, which is in the status "active". This sub-element serviceEvent/statusCode is optional. When it is not present the serviceEvent is assumed to be in the status "completed".

(XeHdotsnOf)
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.4 ActStatusActiveCompleted (DYNAMIC)
hl7:performer
 		0 … *

Laboratory Performer template in the CDA header


Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC) 		(XeHdotsnOf)