1.3.6.1.4.1.19376.1.3.1.1.2

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Case Identification 1.3.6.1.4.1.19376.1.3.1.1.2

Case Identification, when present, SHALL be recorded as an observation in an entryRelationship under the 'Specimen Act' of a Laboratory data processing entry (1.3.6.1.4.1.19376.1.3.1) as demonstrated in the figure below. Case Identification SHALL be present when dictated by local case identification reporting requirements.

The figure below shows how the information for this element is coded, and further constraints are provided in the following sections.

Uses

See Templates using Case Identification

Specification

Case Identification Example

<ClinicalDocument> ... <component typeCode="COMP"> <structuredBody classCode="DOCBODY" moodCode="EVN"> <component typeCode="COMP"> <section classCode="DOCSECT"> <templateId extension="??" root="1.3.6.1.4.1.19376.1.3.3.2.1"/> <code code="18725-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MICROBIOLOGY STUDIES"/> <entry typeCode="DRIV"> <templateId extension="Lab.Report.Data.Processing.Entry" root="1.3.6.1.4.1.19376.1.3.1"/> <text/> <act classCode="ACT" moodCode="EVN"> <entryRelationship typeCode="COMP"> <organizer classCode="CLUSTER" moodCode="EVN"> <component> <observation classCode="COND" moodCode="EVN"> <templateId extension="??" root="1.3.6.1.4.1.19376.1.3.1.1.1"/> ... </observation> </component> <component> <observation classCode="CASE" moodCode="EVN"> <templateId extension="??" root="1.3.6.1.4.1.19376.1.3.1.1.2"/> <id extension="SALM_83747" root="1.19.6.11.13"/> <code="416341003" codeSystem="2.16.840.1.113883.6.96 codeSystemName="SNOMED-CT" displayName="Case Started"> <statusCode code="completed"/> <effectiveTime value="20080408000000.0000-0400"/> <value xsi:type="CE" code="27268008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Salmonella"/> </observation> </component> <component> <observation classCode="OUTB" moodCode="EVN"> <templateId extension="??" root="1.3.6.1.4.1.19376.1.3.1.1.3"/> ... </observation> </component> </organizer> </entryRelationship> </act> </entry> </section> </component> <component> <section> <templateId extension="??" root="1.3.6.1.4.1.19376.1.3.3.2.1"/> <code code="18725-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MICROBIOLOGY STUDIES"/> <title>Laboratory Microbiology Results</title> <text/> <entry typeCode="DRIV"> <templateId extension="Lab.Report.Data.Processing.Entry" root="1.3.6.1.4.1.19376.1.3"/> <act classCode="ACT" moodCode="EVN"> ... </act> </entry> </section> </component> </structuredBody> </component> </ClinicalDocument>

<observation classCode="CASE" moodCode="EVN">

The Case Identification Observation shall be recorded as shown above, classCode "CASE" and moodCode "EVN".

<templateId root="1.3.6.1.4.1.19376.1.3.1.1.2"/>

The <templateId> element identifies this <observation> as the Case Identification. The templateId shall be recorded as shown above, root="1.3.6.1.4.1.19376.1.3.1.1.2".

The Case Identifier Observation shall contain a unique public health code.

<value/>

The Case Identifier Observation value shall specify the specific public health notifiable condition. Eg, Salmonella, Rabies, Bacillus anthracis.