1.3.6.1.4.1.19376.1.3.3.1.2.1

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Non-Human Subject 1.3.6.1.4.1.19376.1.3.3.1.2.1

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 scenario 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 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.
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 sample taken from a non-human subject, such as an animal, a lake, soil or other environmental element, the subjects under the 'Specimen Act' shall be present and shall represent the non-human subject of laboratory testing. When recordTarget.patientRole.patient.nullFlavor is set to "OTH", then recordTarget.patientRole.id shall represent the id of the non-human laboratory test subject. For more information, refer back to 1.3.6.1.4.1.19376.1.3.3.1.2. On a special note, at present, if the document contains both a patient and a subject (as in the case of rabies), documentation of the id of the subject cannot be accomplished without an extension to CDA.

When the subject is present, the following shall be present:

Uses

See Templates using Non-Human Subject

Specification

Non-Human Subject Example

         <subject>
            <templateId root="1.3.6.1.4.1.19376.1.3.3.1.2.1"/>
            <relatedSubject>
                <code code="18998007" codeSystem="2.16.840.1.113883.6.96" 
                      codeSystemName="SNOMED-CT" displayName="Ferret species">
                    <qualifier>
                        <name code="105590001" codeSystem="2.16.840.1.113883.6.96" 
                              codeSystemName="SNOMED-CT" displayName="Substance"/>
                        <value code="39866004" codeSystem="2.16.840.1.113883.6.96" 
                               codeSystemName="SNOMED-CT" displayName="Animal"/>
                    </qualifier>
                 </code>
                 <addr>
                    <streetAddressLine>304 Portola Road</streetAddressLine>
                    <city>San Jose</city> 
                    <state>CA</state> 
                    <postalCode>95120</postalCode> 
                    <country>USA</country> 
                 </addr>
            </relatedSubject>
         </subject>

<templateId root='1.3.6.1.4.1.19376.1.3.3.1.2.1'/>

The <templateId> element identifies this <subject> as a non-human subject of laboratory testing. The templateId must have root='1.3.6.1.4.1.19376.1.3.3.1.2.1'.

<relatedSubject/>

The subject shall have a relatedSubject sub-element.

<code>

Subject.code shall be present and shall represent the type of animal or material tested (ex. chicken, fish, egg salad, water, soil, air, paint, etc.).

<addr>

Subject.addr may be present and shall represent the location where this subject was found or originated (ex. farm address, restaurant address, factory address, reservoir address, etc.) If in the event a unit of information is not known or has been de-identified, the use of nullFlavor is appropriate.

Non-Human Subject <recordTarged> mark-up

In addition to this Subject element for the non-human subject, the recordTarget element described in 1.3.6.1.4.1.19376.1.3.3.1.2 shall also be present in the CDA header.