Progetto

Supplemento 3 all’allegato 4 OCIP-DFI: Referto di laboratorio elettronico RS 816.111

Content

1. Templates .................................................................................................................................................. 4 1.1. CDA Document Level Templates ........................................................................................................ 4 1.1.1. Laboratory Report V1 .................................................................................................................. 4 1.2. CDA Header Level Templates ........................................................................................................... 20 1.2.1. Document Templates................................................................................................................. 20 1.2.2. Document Code ......................................................................................................................... 21 1.2.3. Recipient .................................................................................................................................... 22 1.2.4. Patient (recordTarget)................................................................................................................ 24 1.2.5. Author ........................................................................................................................................ 26 1.2.6. Custodian ................................................................................................................................... 28 1.2.7. Legal Authenticator .................................................................................................................... 30 1.2.8. Document Title........................................................................................................................... 31 1.2.9. Document Replacement ............................................................................................................ 32 1.2.10. Insurance Card .......................................................................................................................... 34 1.2.11. Insurance ................................................................................................................................... 36 1.2.12. Order reference ......................................................................................................................... 39 1.2.13. Confidentiality Code................................................................................................................... 40 1.2.14. Set Id and Version Number ....................................................................................................... 41 1.2.15. Document language................................................................................................................... 42 1.2.16. Document Id .............................................................................................................................. 43 1.2.17. Realm ........................................................................................................................................ 44 1.2.18. Non-Human Subject (recordTarget) .......................................................................................... 45 1.2.19. Non-Human Subject .................................................................................................................. 46 1.2.20. Human Patient with Non-Human Subject (recordTarget) .......................................................... 47 1.2.21. Human Patient with Non-Human Subject .................................................................................. 48 1.2.22. Laboratory Performer (documentationOf).................................................................................. 50 1.2.23. Data Enterer .............................................................................................................................. 52 1.3. CDA Section Level Templates........................................................................................................... 53

1.3.1. Laboratory Speciality Section .................................................................................................... 53 1.3.2. Coded Vital Signs Section ......................................................................................................... 58 1.3.3. Coded Results ........................................................................................................................... 61 1.4. CDA Entry Level Templates .............................................................................................................. 62

1.4.1. Participant (Body, device) .......................................................................................................... 62 1.4.2. Specimen Collection .................................................................................................................. 64 1.4.3. Specimen Received ................................................................................................................... 68 1.4.4. Case Identification ..................................................................................................................... 71 1.4.5. Laboratory Isolate Organizer ..................................................................................................... 73 1.4.6. Multimedia Embedded Content ................................................................................................. 79