1.3.6.1.4.1.19376.1.3.3.1.3

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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

Human Patient with Non-Human Subject 1.3.6.1.4.1.19376.1.3.3.1.3

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 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, but the lab result findings directly impact a single patient (such as in the case of rabies) 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. Information pertaining to the non-human subject of the laboratory testing is in the body of the document.

Uses

See Templates using Human Patient with Non-Human Subject

Specification

Human Patient with Non-Human Subject Example

  <recordTarget typeCode="RCT">
    <templateId root="1.3.6.1.4.1.19376.1.3.3.1.3"/>
    <patientRole classCode="PAT">
       <id extension="sw54321" root="1.3.6.1.4.1.19376.1.3.4"/>
      <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="1.3.6.1.4.1.19376.1.3.3.1.3"/>
    <patientRole classCode="PAT">
       <id extension="sw54321" root="1.3.6.1.4.1.19376.1.3.4"/>
      <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>

<templateId root="1.3.6.1.4.1.19376.1.3.3.1.3"/>

The <templateId> element identifies this <recordTarget> as a human patient directly impacted by a non-human subject of laboratory testing. The templateId SHALL have root='1.3.6.1.4.1.19376.1.3.3.1.3'.

<patientRole>

<id/>

ClinicalDocument.recordTarget.patientRole.id SHALL be present

<addr/>

ClinicalDocument.recordTarget.patientRole.addr SHALL be present

<telecom/>

ClinicalDocument.recordTarget.patientRole.telecom SHALL be present

<patient/>

<name/>

ClinicalDocument.recordTarget.patientRole.patient.name SHALL be present

<administrativeGenderCode/>

ClinicalDocument.recordTarget.patientRole.patient.administrativeGenderCode SHALL be present

<birthTime/>

ClinicalDocument.recordTarget.patientRole.patient.birthTime SHALL be present

Human Patient with Non-Human Subject <structuredBody> mark-up

In addition to the elements specified in the CDA header,above, for the human patient, the non-human subject shall be represented in a Subject element as described in Non-Human Subject shall also be present in level 3 markup in the <structuredBody>.