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THIS HAS BEEN DEPRECATED
There are three varieties of XDS-Lab documents: Human (patient), Non-Human Subject, Human(patient) with Non-Human Subject. For each variety we provide a short scenaio below to aid in the distinction among the varieties.
- Human (patient): Shelly Winters appears at the hospital emergency room with a jar of recalled peanut butter and symptoms consistent with Salmonellosis. Her physician, Dr Patel, orders a stool culture and prescribes an initial antibiotic treatment. The hospital laboratory performs the stool culture test and identifies Salmonella group C. The patient’s history and isolate are sent to the local public health laboratory for epidemiological testing and confirmation of the relationship to the known outbreak. The public health laboratory performs further testing and confirms the patient is part of the existing outbreak. The reportable condition is escalated to additional recipients indicated in the report that is shared with the care provider and additional public health agencies.
- Non-Human Subject: Water, milk, and meat samples are routinely tested to meet various regulatory requirements. Water testing includes municipal drinking water, well water, open swimming beaches, and public pools to test for coliform levels. Milk samples are tested for total bacteria counts prior to pasteurization. Meat is tested for harmful bacteria such as Escherichia coli 0157:H7.
- Human(patient) with Non-Human Subject: Animal control authorities bring to the public health laboratory the head of a ferret that ferociously pursued and bit a young child. The specimen is to be tested for Rabies to determine if the child must undergo Rabies immunization. The public health laboratory gets the incident information and performs the rabies test while the child’s physician awaits the results. The rabies test is negative. A public health laboratory report is created for the physician that references the child as the patient and the test subject as the ferret.
When the lab test subject is a biological sample taken from a human patient, the following SHALL be present. XDS-Lab does not further refine the meaning of these elements beyond what is stated in the CDA R2 documentation.
<recordTarget typeCode="RCT"> <templateId root="188.8.131.52.4.1.193184.108.40.206.1.1"/> <patientRole classCode="PAT"> <id extension="sw54321" root="220.127.116.11.4.1.19318.104.22.168"/> <addr> <streetAddressLine>1313 Mockingbird Lane</streetAddressLine> <city>Janesville</city> <state>WI</state> <postalCode>53545</postalCode> <country>USA</country> </addr> <telecom value="tel:608-555-5555"/> <patient classCode="PSN"> <name><family>Winters</family><given>Shelly</given></name> <administrativeGenderCode code="F"/> <birthTime value="19401213000000.0000-0500"/> </patient> </patientRole> </recordTarget>
If in the event a unit of information about the patient is not known or has been de-identified, the use of nullFlavor is appropriate.
<recordTarget typeCode="RCT"> <templateId root="22.214.171.124.4.1.193126.96.36.199.1.1"/> <patientRole classCode="PAT"> <id extension="sw54321" root="188.8.131.52.4.1.193184.108.40.206"/> <addr> <streetAddressLine nullFlavor="MSK"/> <!-- masked value --> <city nullFlavor="MSK"/> <!-- masked value --> <state nullFlavor="MSK"/> <!-- masked value --> <postalCode>53545</postalCode> <country>USA</country> </addr> <telecom nullFlavor="UNK"/> <!-- unknown value --> <patient classCode="PSN"> <name nullFlavor="MSK"/> <!-- masked value --> <administrativeGenderCode code="F"/> <birthTime value="19401213000000.0000-0500"/> </patient> </patientRole> </recordTarget>
The <templateId> element identifies this <recordTarget> as a human patient as the subject of laboratory testing. The templateId SHALL have root='220.127.116.11.4.1.19318.104.22.168.1.1'.
ClinicalDocument.recordTarget.patientRole.id SHALL be present
ClinicalDocument.recordTarget.patientRole.addr SHALL be present
ClinicalDocument.recordTarget.patientRole.telecom SHALL be present
ClinicalDocument.recordTarget.patientRole.patient.name SHALL be present
ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode SHALL be present
ClinicalDocument.recordTarget.patientRole.patient.birthTime SHALL be present