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draft Template  XeH DocumentationOf (report)

Id 2.16.840.1.113883.3.1937.99.61.67.10.14
ref
sxehealth-
Effective Date 2020‑10‑28 12:24:01
Status draft Draft Version Label wip
Name XeHReportDocumentationOf Display Name XeH DocumentationOf (report)
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
2.16.840.1.113883.2.51.10.2 Include draft XeH Diagnostic Imaging Report (0.1) 2021‑06‑21 14:23:14
Uses as Name Version
1.3.6.1.4.1.19376.1.3.3.1.7 Containment active Laboratory Performer (2017) DYNAMIC
Relationship Adaptation: template 1.3.6.1.4.1.19376.1.3.10.9.15 XD-LAB DocumentationOf (2016‑07‑05)
ref
XDLAB-
Item DT Card Conf Description Label
hl7:documentationOf
0 … * (XeHdotsnOf)
hl7:serviceEvent
1 … 1 R (XeHdotsnOf)
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)