MEDRPT Medical service report

TBG10 Healthcare

A Medical Service Report message is sent from a service provider to the service requester to report new results on performed investigations, to modify a previous result item or a complete result report or to cancel a previous result report.

Header

Position
Segment
Name
Max use
  1. A service segment starting and uniquely identifying a message. The message type code for the Medical service report message is MEDRPT. Note: Medical service report messages conforming to this document must contain the following data in segment UNH, composite S009: Data element 0065 MEDRPT 0052 D 0054 19B 0051 UN

  2. A segment for unique identification of the message and specification of its function.

  3. A segment identifying the date and/or time of message generation and/or other dates and/or times concerning the whole message.

  4. A segment giving free text information, in coded or clear form, for specifying information concerning the whole message.

  5. Segment group 1
    Repeat 99
    1. A segment for specifying the identification, name and address of involved healthcare organisations or professionals.

    2. A segment for specifying the address of the actual healthcare party.

    3. A segment giving communication numbers for the actual healthcare party.

    4. A segment with free text information, in coded or clear form, for specifying unstructured telecommunication numbers of the actual healthcare party including electronic mail address.

    5. A segment for specifying alternative identification numbers of the actual healthcare party assigned by the involved healthcare parties. This segment also keeps a reference to another party if the current party is related to another party such as department in a hospital, a physician in a department, etc.

    6. A segment for allocating a sequence number to the individual healthcare party allowing each healthcare party to be referenced from within the message.

    7. A segment for specifying the language used by the actual healthcare party.

    8. A segment for specifying the type and medical speciality of a healthcare organisation.

    9. A segment for specifying the professional medical qualifications of a person.

    10. A segment for specifying the type, medical speciality and the position or military rank of a healthcare professional.

  6. Segment group 2
    Repeat 99
    1. A segment for specifying the requirements concerning acknowledgment of the report.

    2. A segment for specifying the service type of the actual report, i.e. whether this is a new report, a modification to a previously issued report, etc.

    3. A segment for specifying the identification of the service report as provided by the service provider. This segment also keeps a reference to a healthcare party related to this service report which is specified in segment group 1.

    4. A segment for specifying the issue date and/or time of the report and/or other dates and/or times relevant to the report.

    5. A segment for specifying the status of the service report, i.e. whether it is a partial report, a complete report, etc.

    6. A segment for specifying the reporting priority of the service report.

    7. A segment specifying the language of the actual report.

    8. A segment with free text information, in coded or clear form, for specifying the comments of the service provider concerning the complete report and/or the reason for cancellation.

    9. A segment for specifying the reason for cancellation of the complete report.

    10. Segment group 3
      Repeat 99
      1. A segment for specifying the identification number of the referenced service report.

      2. A segment specifying the issue date and/or time of the referenced service report.

    11. Segment group 4
      Repeat 99
      1. A segment giving information concerning payment category for this order.

      2. A segment for specifying the identification number of the order allocated by various healthcare parties, such as service requester, service provider, etc. The segment is also used for referencing a related healthcare party specified in segment group 1.

      3. A segment to provide the service type of the service order, i.e. new order, order modification, etc.

      4. A segment specifying the dates and/or times concerning the order such as issue date of order, date of receipt, due date of report, etc.

      5. A segment specifying the requested reporting priority for the whole order.

      6. A segment for specifying the reason for request as well as comments from the requester as a diagnosis concerning this order.

      7. A segment with free text information, in coded or clear form, for specifying the reason for request as well as comments from the requester concerning this order.

      8. A segment for specifying the reason for the request.

      9. Segment group 5
        Repeat 99
        1. A segment for specifying the document name.

        2. A segment for specifying the identification number of the referenced order.

        3. A segment for specifying the issue date and/or time of the referenced order.

    12. Segment group 6
      Repeat 99
      1. A segment for specifying the type of subject of investigation.

      2. A segment for specifying the identification numbers of the actual subject of investigation.

      3. A segment for specifying the address details of the subject of investigation.

      4. A segment providing a telecommunication number of the subject or investigation.

      5. A segment for specifying the association between subjects of investigation such as donor, foetus, etc. as well as the relationship of a related person to the patient.

      6. A segment for specifying the description of the material being investigated if the subject of investigation is a material.

      7. A segment with free text information, in coded or clear form, for specifying additional information about the material as well as an unstructured telecommunication number of the subject of investigation.

      8. A segment for identifying the patient and related person or name by specifying various patient name details and official patient ID.

      9. A segment for specifying relevant date and/or times for the patient such as date of birth, date of death, etc.

      10. A segment for specifying demographic information such as sex, marital status and religion.

      11. A segment for specifying the nationality of a person.

      12. A segment for specifying the language used by the person.

      13. A segment for specifying the confidentiality constraints on patient data.

      14. A segment for specifying the species or breed of an animal.

      15. Segment group 7
        Repeat 9
        1. A segment for specifying patient administrative information such as administrative status concerning actual hospital stay or out-patient visit or ward stay related to the subject of investigation.

        2. A segment for specifying the physical patient care location in terms of ward, room, bed, etc.

        3. A segment for specifying admission and/or discharge date and time or start and/or end date and time of a ward stay.

        4. This segment keeps a reference to a healthcare party for specifying healthcare administrative information such as hospital, department, etc. where patient is admitted, located, etc.

      16. Segment group 8
        Repeat 999
        1. A segment for specifying the type of clinical information.

        2. A segment for specifying the type of clinical observation, description of the clinical observation itself as well as the degree of certainty concerning the clinical observation.

        3. A segment for specifying the language related to the clinical observation.

        4. A segment for specifying date and times related to the clinical information, the clinical observation itself and the origin of clinical information.

        5. A segment with free text information, in coded or clear form, for description of the clinical information.

        6. This segment keeps a reference to a healthcare party for specifying origin of clinical information.

        7. Segment group 9
          Repeat 99
          1. A segment for specifying the status of the clinical investigation, e.g. preliminary results, final results, etc.

          2. A segment for allocating a sequence number to a clinical investigation result item to allow referencing from within this message to a specific clinical investigation result item.

          3. A segment for specifying the service type of the clinical investigation result item, e.g. new result item.

          4. A segment for specifying the numerical value or a coded text value of a clinical investigation result item including unit of measurement, arithmetic comparator and the deviating result indicator.

          5. A segment for identifying the clinical investigation and to describe specifications to the clinical investigation.

          6. A segment giving a text value of a clinical investigation result item as well as a comment to the clinical investigation result item as a diagnosis.

          7. A segment for specifying relevant date and times concerning the investigation such as date and time for investigation performed, last status change and a date value of a clinical observation.

          8. A segment with free text information, in coded or clear form, for specifying the text value of a clinical investigation as well as comments to the clinical investigation and the investigation result item.

          9. This segment keeps a reference to the "parent" clinical investigation result item if needed.

          10. Segment group 10
            Repeat 99
            1. A segment for specifying the numerical reference interval of an investigation result item and the type of reference interval.

            2. A segment with free text information, in coded or clear form, for specifying the textual reference limits of an investigation result item.

            3. A segment for specifying a reference population, e.g. age, sex, smokers, etc.

          11. Segment group 11
            Repeat 99
            1. A segment for specifying the type of relationship of a related healthcare service provider to the clinical investigation result item.

            2. A segment for specifying a reference to healthcare parties in segment group 1 where the related healthcare professional or organisation is identified.

        8. Segment group 12
          Repeat 99
          1. A segment for specifying the type of intervention and the intervention itself.

          2. Segment group 13
            Repeat 99
            1. A segment for identifying a drug.

            2. A segment for specifying the dosage and administration specifications of a drug.

            3. A segment with free text information, in coded or clear form, for specifying dosage and administration specification of a drug.

            4. A segment for specifying the dosage regime.

      17. Segment group 14
        Repeat 99
        1. A segment for allocating a sequence number to the sample to allow referencing from within this message to a specific sample.

        2. A segment for specifying the characteristics of a sample like type of sample, anatomical origin and sample preservation material.

        3. A segment for specifying information about type of collection procedure and subsequent handling of the sample.

        4. A segment for specifying the identification numbers of the actual sample allocated by service requester and service provider. This segment also keeps a reference to healthcare parties related to this actual sample such as the sample collector and sample collection location. This segment in addition keeps a reference to the "parent" sample if this sample is part of or derived from another sample.

        5. A segment for specifying information about sample volume or weight.

        6. A segment for specifying relevant dates and times concerning the sample such as start and/or end date and time or period for sample collection, sample receipt date and time, etc.

        7. A segment specifying the number of sample containers this sample consists of.

        8. A segment with free text information, in coded or clear form, expressing the comments of the sample collector, the comments of the requester or service provider to the sample, anatomical origin of sample, sample location description, etc.

        9. A segment for specifying the transport logistics of the collected sample.

          040 D5(040,030) If first, then all
        10. A segment for specifying sample handling warning.

        11. A segment for specifying the location for sample collection in terms of hospital ward, room and bed number.

        12. A segment for specifying the address for the sample collection.

        13. Segment group 15
          Repeat 99
          1. A segment for describing the pre-treatment administered.

          2. A segment for specifying the substance administered for pre-treatment.

          3. A segment for specifying the route of administration of the pre-treatment.

          4. A segment for specifying relevant date and times for the pre-treatment like start, end or duration of administration.

          5. A segment with free text information, in coded or clear form, for describing the pre-treatment.

          6. A segment for specifying amount of substance administered.

          7. A segment for specifying the dosage regime.

      18. Segment group 16
        Repeat 99
        1. A segment for specifying the line number of the laboratory investigation result item.

        2. A segment for specifying the service type of the result of this investigation, e.g. new result, corrected result, etc.

        3. A segment for specifying the numerical value or a coded text value of an investigation result item including unit of measurement, arithmetic comparator and the deviating result indicator.

        4. A segment for specifying the characteristics of the investigation. The characteristics may concern system, component or property examined as well as method of measurement, etc.

        5. A segment for specifying the result of an investigation or comments to a result item as a diagnosis.

        6. A segment for allocating a sequence number to this result item to allow for referencing from within this message to a specific result item.

        7. A segment for specifying the status of an investigation or investigation result item, e.g. unverified result, preliminary result, etc.

        8. A segment for specifying date and times relevant for this investigation result item such as date and time of investigation performed, status change, etc. The segment may also carry the result of an investigation if this is expressed as a date or period such as clinical dates.

        9. A segment with free text information, in coded or clear form, for specifying a result item as a text value as well as comments to the result item or the investigation itself.

        10. A segment for specifying the type of cost, the amount of cost and possibly currency unit used concerning the investigation.

        11. This segment keeps a reference to one or more samples related to this actual result item such as the sample(s) involved in obtaining this result item. This segment also keeps a reference to another investigation result item related to this actual investigation result item such as the investigation result item which this investigation result item is part of.

        12. A segment for specifying the measuring equipment used for obtaining this investigation result item.

        13. Segment group 17
          Repeat 99
          1. A segment for specifying the type of relationship a service provider has to the produced investigation result item.

          2. This segment keeps a reference to a healthcare party (healthcare professional or healthcare organisation) which is identified in segment group 1 for specifying a related person or organisation.

        14. Segment group 18
          Repeat 99
          1. A segment for specifying the reference interval for the investigation and the type of reference interval such as physiological, therapeutical, etc.

          2. A segment with free text information, in coded or clear form, for specifying textual reference limits concerning the investigation.

          3. A segment for specifying the reference population.

  7. Segment group 19
    Repeat 99
    1. A segment for specifying results of an authentication procedure.

    2. A segment for specifying the date and time for the validity of the authentication.

  8. A service segment ending a message, giving the total number of segments in the message (including the UNH & UNT) and the control reference number of the message.

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