1.3.6.1.4.1.19376.1.3.3.2.1

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Return to: XDS-LAB Harmonization
Return to: Laboratory Content Modules
Return to:Laboratory Report Summary Specification

This text needs to be fixed-->> need better presentation of list of loinc codes and display name pairs<<--

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 https://www.ihe.net/resources/technical_frameworks/#pcc

Trial.gif Laboratory Specialty Section
Template ID 1.3.6.1.4.1.19376.1.3.3.2.1
General Description

Every Lab Summary Report SHALL contain at least one Laboratory Specialty Section. Each section represents a specialty. A laboratory report MAY be composed of test results from a single specialty (e.g. a microbiology report, a virology report), or from any number of specialties (a report from a multidisciplinary laboratory). The structure of the report allows both kinds of reports.

LOINC Code Opt Description
18717-9,18718-7,18719-5,18720-3,18721-1,18722-9,19723-7,18724-5,18725-2,18727-8, 18728-6,18729-4,18767-4,18768-2,18769-0,26435-8,26346-6,26437-4, 26438-2 R BLOOD BANK STUDIES,CELL MARKER STUDIES,CHEMISTRY STUDIES,COAGULATION STUDIES,THERAPEUTIC DRUG MONITORING STUDIES,FERTILITY STUDIES,HEMATOLOGY STUDIES,HLA STUDIES,MICROBIOLOGY STUDIES,SEROLOGY STUDIES,TOXICOLOGY STUDIES,URINALYSIS STUDIES,BLOOD GAS STUDIES,CELL COUNTS+DIFFERENTIAL STUDIES,MICROBIAL SUSCEPTIBILITY TESTS,MOLECULAR PATHOLOGY STUDIES,LABORATORY STUDIES,CHEMISTRY CHALLENGE STUDIES,CYTOLOGY STUDIES(add notes p24)
Entries Opt Description
1.3.6.1.4.1.19376.1.3.1 R Lab Report Data Processing Entry
Subsections Opt Description
1.3.6.1.4.1.19376.1.3.3.2.2 O Laboratory Report Item Section



Sample Laboratory Specialty Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.3.3.2.1'/>
    <id root=' ' extension=' '/>
    <code code='18717-9,18718-7,18719-5,18720-3,18721-1,18722-9,19723-7,18724-5,18725-2,18727-8, 18728-6,18729-4,18767-4,18768-2,18769-0,26435-8,26346-6,26437-4, 26438-2' displayName='BLOOD BANK STUDIES,CELL MARKER STUDIES,CHEMISTRY STUDIES,COAGULATION STUDIES,THERAPEUTIC DRUG MONITORING STUDIES,FERTILITY STUDIES,HEMATOLOGY STUDIES,HLA STUDIES,MICROBIOLOGY STUDIES,SEROLOGY STUDIES,TOXICOLOGY STUDIES,URINALYSIS STUDIES,BLOOD GAS STUDIES,CELL COUNTS+DIFFERENTIAL STUDIES,MICROBIAL SUSCEPTIBILITY TESTS,MOLECULAR PATHOLOGY STUDIES,LABORATORY STUDIES,CHEMISTRY CHALLENGE STUDIES,CYTOLOGY STUDIES(add notes p24)'
      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>
    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.3.3.2.2'/>
        <!-- Optional  Laboratory Report Item Section Section content -->
      </section>
    </component>

       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.3.3.2.1'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.3.3.2.1"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Laboratory Specialty can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "18717-9,18718-7,18719-5,18720-3,18721-1,18722-9,19723-7,18724-5,18725-2,18727-8, 18728-6,18729-4,18767-4,18768-2,18769-0,26435-8,26346-6,26437-4, 26438-2"]'> 
     Error: The section type code of a Laboratory Specialty must be 18717-9,18718-7,18719-5,18720-3,18721-1,18722-9,19723-7,18724-5,18725-2,18727-8, 18728-6,18729-4,18767-4,18768-2,18769-0,26435-8,26346-6,26437-4, 26438-2 
   </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 = "1.3.6.1.4.1.19376.1.3.3.2.2"]'> 
     <!-- Note any missing optional elements -->
     Note: This Laboratory Specialty Section does not contain a(n)  Laboratory Report Item Section Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.3.3.2.1
   </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 Specialty Section must contain a(n) Lab Report Data Processing Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.3.3.2.1
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Laboratory Specialty Section


Laboratory Specialty Section Rendering

Every Lab Summary Report SHALL contain at least one Laboratory Specialty Section. Each section represents a specialty. A laboratory report MAY be composed of test results from a single specialty (e.g. a microbiology report, a virology report), or from any number of specialties (a report from a multidisciplinary laboratory). The structure of the report allows both kinds of reports.

The “specialty” sections SHALL use the LOINC codes defined as report subject identifier codes. A clinical laboratory report SHALL contain one or more of these sections, in any order. These “specialty” sections SHALL NOT be nested.


LOINC Code (Name)

  • 18717-9 (BLOOD BANK STUDIES)
  • 18718-7 (CELL MARKER STUDIES)
  • 18719-5 (CHEMISTRY STUDIES)
  • 18720-3 (COAGULATION STUDIES)
  • 18721-1 (THERAPEUTIC DRUG MONITORING STUDIES)
  • 18722-9 (FERTILITY STUDIES)
  • 18723-7 (HEMATOLOGY STUDIES)
  • 18724-5 (HLA STUDIES)
  • 18725-2 (MICROBIOLOGY STUDIES)
  • 18727-8 (SEROLOGY STUDIES)
  • 18728-6 (TOXICOLOGY STUDIES)
  • 18729-4 (URINALYSIS STUDIES)
  • 18767-4 (BLOOD GAS STUDIES)
  • 18768-2 (CELL COUNTS+DIFFERENTIAL STUDIES)
  • 18769-0 (MICROBIAL SUSCEPTIBILITY TESTS)
  • 26435-8 (MOLECULAR PATHOLOGY STUDIES)
  • 26436-6 (LABORATORY STUDIES)
  • 26437-4 (CHEMISTRY CHALLENGE STUDIES)
  • 26438-2 (CYTOLOGY STUDIES)


Note 1: 26436-6 (LABORATORY STUDIES) enables issuing a report putting together observations from multiple specialties (disciplines) in the same text block, allowing delivery of a global interpretation comment at the end of the text block, that will be rendered at the end of the report.

Note 2: 18721-1 (THERAPEUTIC DRUG MONITORING STUDIES) SHALL be used for a section carrying pharmacology observations on a patient.

Note 3: Mycology and parasitology, as well as bacteriology, are part of the 18725-2 (MICROBIOLOGY STUDIES) specialty.

Note 4: Virology MAY be included in 18725-2 (MICROBIOLOGY STUDIES) specialty or 18727-8 (SEROLOGY STUDIES) or split between both specialties, depending upon the Content Creator Actor’s choice.


Laboratory Specialty Section Constraints

<section>

Every Laboratory Report SHALL contain at least one Laboratory Specialty Section. Each section represents a LOINC specialty.

<templateId root="1.3.6.1.4.1.19376.1.3.3.2.1"/>

The <templateId> element identifies this <section> as a Specialty Section. The templateId SHALL be recorded as shown above, root="1.3.6.1.4.1.19376.1.3.3.2.1".

The Specialty Section SHALL identify the LOINC laboratory specialty. The code, codeSystem, and displayName SHALL be present. The codeSystemName MAY also be present.

<title/>

The Specialty Section <title> MAY be present.

Laboratory Speciality Section Options

A Specialty Section contains EITHER a Laboratory Leaf Section OR a <text> and <entry> element to represent the Report Items. 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).

Option 1: Laboratory Leaf Section

With this option, this Specialty Section SHALL contain neither <text> nor <entry> elements. Each Report Item is contained in one Laboratory Leaf Section which contains the Lab Report Data Processing Entry.

Option 2: Text and Entries

<text> With this option, the Specialty Section <text/> SHALL be present and not blank. This narrative block SHALL present to the human reader, all the observations produced for this Specialty, 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> With this option, the Specialty Section <entry> SHALL be present with attribute typeCode="DRIV". This <entry> contains the machine-readable result data from which the narrative block of this section is derived. See: Lab Report Data Processing Entry

Laboratory Specialty 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 a leaf section. -->
          <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"/>
              <!-- Example 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>
        </section>
      </component>
      <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 Report Items directly rather than using leaf sections. -->
          <code code="18719-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="CHEMISTRY STUDIES"/>
          <title>Laboratory Chemistry Results</title>
          <text/>
          <entry typeCode="DRIV">
            <templateId root="1.3.6.1.4.1.19376.1.3"/>
            <act classCode="ACT" moodCode="EVN">
              ...
            </act>
          </entry>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>
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