ABCDEFGHIJKLMNOPQRSTUVWXYZ
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SpecificationArtefactTemplateCommentsContraints
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XD-LAB profile (IHE PaLM)Clinical laboratory report (CDA R2)
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http://www.ihe.net/uploadedFiles/Documents/PaLM/IHE_PaLM_TF_Vol3.pdfTop level section [1..*]Laboratory Specialty Section (1.3.6.1.4.1.19376.1.3.3.2.1)Example: hematology, urinalysis, chemistry, molecular, laboratory studiesContains either a <text> bloc and a single Laboratory Report Data Processing entry, or a list of embedded Laboratory Report Item sections
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embedded section [0..*]Laboratory Report Item Section (1.3.6.1.4.1.19376.1.3.3.2.2)Can be a study, a panel, a testThis level of section is not mandatory
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section/textNo template, but best practice:
Vol 3:6.3.3.2.2 Recommendations for Narrative Text		Time of specimen collection, reference ranges, method, interpretation, previous results …<text> is fully derived from the content of the entry(ies)
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entry/actLaboratory Report Data Processing Entry (1.3.6.1.4.1.19376.1.3.1)act/code (LOINC) represents either a specialty or a reportable item (if two levels of section)<entry typeCode="DRIV">
entry/act MAY contain any number of Isolate organizers, battery organizers, laboratory observations, multimedia contents, comments, specimen collection, specimen received.
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act/organizer [classCode="CLUSTER"]Laboratory Isolate Organizer 1.3.6.1.4.1.19376.1.3.1.5Organizes all the results obtained on an isolate in microbio (e.g.; AST)MAY contain any number of battery organizers, laboratory observations, multimedia contents, comments.
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organizer [classCode="BATTERY"]Laboratory Battery Organizer 1.3.6.1.4.1.19376.1.3.1.4Organizes the results of a battery or panel.code from LOINC or SNOMED CT
statusCode = completed or aborted
MAY contain any number of laboratory observations, multimedia contents, comments, specimen collection
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observationLaboratory Observation 1.3.6.1.4.1.19376.1.3.1.6The result of a lab testSHALL have code and statusCode (completed/aborted)
MAY contain identifier, value, time, method, interpretation, author, performer (including device or subcontractor lab), subject, verifier, previous results, reference ranges, specimen collection, comments.
code: LOINC not mandated because of Japan's JLAC10
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commentAnnotation Comment (PCC) 1.3.6.1.4.1.19376.1.5.3.1.4.2in common with IHE PCC
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IHE PCC library of contentused by many document templates (notes and summaries)
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http://www.ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_TF_Vol2.pdf
section
Coded Results Section (1.3.6.1.4.1.19376.1.5.3.1.3.28)
SHALL contain:
- text
- Procedure entry
- Simple Observation entry
SHOULD contain External References entry (if known)
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section/text
shall contain a narrative description of the relevant diagnostic procedures the patient received in the past
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http://www.ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_Suppl_CDA_Content_Modules.pdf
entry/procedure
Procedure Entry 1.3.6.1.4.1.19376.1.5.3.1.4.19
The code of diagnostic test or panel that was performed
The procedure entry is used to record procedures that have occurred, or which are planned for
MAY contain the encounter in which it was performed
MAY contain the reason why it was performed (-> concern)
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entry/observation
Simple Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13
an abstract representation of many of the observations used in PCC. Specialized into many other child templates.
SHALL have identifier, code, statusCode="completed", value
MAY have method, interpretation, target site, specif author
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entry/observation
Blood Type Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.6
Specializes Simple ObservationLOINC code 882-1 |ABO+RH GROUP|
Two alternative coding systems for value: SNOMED CT, ISBT 128
SHALL not have target site, method or interpretation
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entry/act
External References 1.3.6.1.4.1.19376.1.5.3.1.4.4
References to external documents or messages
act/reference[typeCode='REFR|SPRT'] (points to an external CDA document)
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http://www.ihe.net/Technical_Framework/upload/IHE_PCC_Suppl_AntepartumProfiles_Rev1-2_TI_2011-09-09.pdfAntepartum summary (APS)Uses Antepartum Laboratory Value Set 1.3.6.1.4.1.19376.1.5.3.1.1.16.5.7 (LOINC-based)
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Antepartum Laboratory Content Profile (APL)
There are no content module mappings for Antepartum Laboratory as XD-LAB profile is referenced in full
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C-CDA R2.1including Continuity of Care Document - CCD V3, and Transfer Summary
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http://www.hl7.org/implement/standards/product_brief.cfm?product_id=408
section [0..1]
Results Section 2.16.840.1.113883.10.20.22.2.3.1
Fits for results generated by laboratories, imaging procedures, and other procedures
section is requird by CCD and Transfer Summary.
It is optional in Consultation Note and Referral Note
SHALL contain text bloc and one or more Result Organizer entries
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section/text
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entry/organizer [classCode="BATTERY"]
Result Organizer 2.16.840.1.113883.10.20.22.4.1
Used by Results Section, Health Concern Act and Risk Concern Act
SHALL have one or more Result Observation
code SHOULD be selected from LOINC or SNOMED CT
code MAY be selected from CPT-4
statusCode active or completed
zero or more author
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organizer/observation
Result Observation 2.16.840.1.113883.10.20.22.4.2
SHALL have id, code (LOINC), statusCode, time, value
SHOULD have interpretation, reference ranges, author
MAY have method and target site
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EU Patient Summary Guideline - Minimal Dataset
Summary includes blood group
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implemented in epSOS > EXPANDsection
Coded Results Section (1.3.6.1.4.1.19376.1.5.3.1.3.28)
Contains text bloc and simple observation entryBlood group; implementation adapted from IHE PCC coded result, using single obseravtion but no procedures
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entry/observation
Simple Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13
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