1.3.6.1.4.1.19376.1.3.3

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Laboratory Report Summary Specification 1.3.6.1.4.1.19376.1.3.3

TODO - description and use case

put list of header conformance statements (4.1 in 2007 version of XDS_Lab, at least those inherent in CRS specification)

Format Code

The XDSDocumentEntry format code for this content is urn:ihe:lab:xds-lab:2008

Parent Template

This document is an instance of the Medical Summary template.

Standards

CDAR2	HL7 CDA Release 2.0
CRS	HL7 Care Record Summary

Data Element Index

Data Elements	HL7 Care Record Summary	CDA Release 2.0
Intended Recipient	?	informationRecipient/intendedRecipient
Referral Ordering Physician	?	participant

Specification

Data Element Name	Opt	Template ID
Intended Recipient	O	1.3.6.1.4.1.19376.1.3.3.1.1
Referral Ordering Physician	O	1.3.6.1.4.1.19376.1.3.3.1.2

Conformance

CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below. A CDA Document may conform to more than one template. This content module inherits from the Medical Summary content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Laboratory Report Summary Document

<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.2'/>
  <templateId root='1.3.6.1.4.1.19376.1.3.3'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Laboratory Report Summary</title>
  <effectiveTime value='20240418012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.3.3.1.1'/>
        <!-- Optional Intended Recipient Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.3.3.1.2'/>
        <!-- Optional Referral Ordering Physician Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.3.3'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.3.3"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Laboratory Report Summary can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.2"]'>
     Error: The parent template identifier for Laboratory Report Summary is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Laboratory Report Summary must be {{{LOINC}}}
   </assert>
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
     Error: The document type code must come from the LOINC code 
     system (2.16.840.1.113883.6.1).
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.3.3.1.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This Laboratory Report Summary Document does not contain a(n) Intended Recipient Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.3.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.3.3.1.2"]'> 
     <!-- Note any missing optional elements -->
     Note: This Laboratory Report Summary Document does not contain a(n) Referral Ordering Physician Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.3.3
   </assert> 
 </rule>
</pattern>