1.3.6.1.4.1.19376.1.3.3.2.2

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Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

Trial.gif Laboratory Report Item Section
Template ID 1.3.6.1.4.1.19376.1.3.3.2.2
General Description Description of lab specialty section
LOINC Code Opt Description
TEST CODE R test code display name
Entries Opt Description
1.3.6.1.4.1.19376.1.3.1 R Lab Report Data Processing Entry



Sample Laboratory Report Item Section
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.3.3.2.2'/>
    <id root=' ' extension=' '/>
    <code code='TEST CODE' displayName='test code display name'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Lab Report Data Processing Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.3.1'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.3.3.2.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.3.3.2.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Laboratory Report Item can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "TEST CODE"]'> 
     Error: The section type code of a Laboratory Report Item must be TEST CODE 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.3.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Laboratory Report Item Section must contain a(n) Lab Report Data Processing Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.3.3.2.2
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Laboratory Report Item Section



Laboratory Leaf Section Rendering

At the second level (nested in one specialty section), each leaf section represents a single Report Item. A Report Item can be a battery (or test panel), an individual test, or the complete study of a specimen (particularly in the MICROBIOLOGY STUDIES specialty).


Laboratory Leaf Section Constraints

<section>

The Leaf Section under one Laboratory Specialty Section SHALL contain only one Report Item.

<templateId root="1.3.6.1.4.1.19376.1.3.3.2.2"/>

The <templateId> element identifies this <section> as a Leaf Section to a Laboratory Specialty Section. The templateId SHALL be recorded as shown above, root="1.3.6.1.4.1.19376.1.3.3.2.2".

<code code=" " codeSystem=" " codeSystemName=" " displayName=" "/>

The Leaf Section SHALL identify the single Report Item uniquely using the <code> element. For example, a LOINC test code. The code, codeSystem, and displayName SHALL be present. You MAY also populate codeSystemName and orginalText.

<title/>

The Leaf Section <title> MAY be present, it is the local translation of the <code> displayName.

<text/>

The Leaf Section <text/> SHALL be present and not blank. This narrative block SHALL present to the human reader, the observations produced for this Report Item, using the various structures available in the CDA Narrative Block schema (NarrativeBlock.xsd): tables, lists, paragraphs, hyperlinks, footnotes, references to attached or embedded multimedia objects. The narrative block is fully derived from the <entry> containing the machine-readable result data.

<entry typeCode="DRIV">

The Leaf Section SHALL contain a Lab Report Data Processing Entry. This <entry> contains the machine-readable result data from which the narrative block of this section is derived.

Laboratory Leaf Section Example

<ClinicalDocument> 
  ...
  <component typeCode="COMP">
    <structuredBody classCode="DOCBODY" moodCode="EVN">
      <component typeCode="COMP">
        <section classCode="DOCSECT">
          <templateId root="1.3.6.1.4.1.19376.1.3.3.2.1"/>
          <!-- Example Specialty Section that holds two leaf sections. -->
          <code code="18723-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HEMATOLOGY STUDIES"/>
          <title>Laboratory Hematology Results</title>
          <component>
            <section>
              <templateId root="1.3.6.1.4.1.19376.1.3.3.2.2"/>
              <!-- Leaf Section that holds one Report Item. -->
              <code code="16931-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Hemoglobin/Hematocrit"/>
              <text/>
              <entry typeCode="DRIV">
                <templateId root="1.3.6.1.4.1.19376.1.3"/>
                <act classCode="ACT" moodCode="EVN">
                  ...
                </act>
              </entry>
            </section>
          </component>
          <component>
            <section>
              <templateId root="1.3.6.1.4.1.19376.1.3.3.2.2"/>
              <!-- Leaf Section that holds one Report Item. -->
              <code code="14196-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Reticulocytes"/>
              <text/>
              <entry typeCode="DRIV">
                <templateId root="1.3.6.1.4.1.19376.1.3"/>
                <act classCode="ACT" moodCode="EVN">
                  ...
                </act>
              </entry>
            </section>
          </component>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>