The legislation

The Decree Law 18 October 2012, n. 179 (so-called “Growth 2.0”), and subsequent amendments, provides for the establishment of the Electronic Health Record (FSE) in article 12 as a set of digital health and social-health data and documents concerning the patient, by the Regions and of the Autonomous Provinces.

The Decree of the President of the Council of Ministers of 29 September 2015, n.178 containing the “Regulations on the Electronic Health Record” contains the technical rules according to which the Regions must prepare their own regional ESF systems. The standard provides for the mandatory use of LOINC codes for the unambiguous identification of the examination carried out within the laboratory report documents in HL7 CDA2 format.

The recent Guidelines for the implementation of the Electronic Health Record have reiterated the importance of adopting dictionaries and standard coding systems to enhance the data contained in clinical documents and ensure their semantic interoperability, and therefore the assignment of a univocally interpretable meaning. for the actors involved. Among them LOINC is identified to encode clinical and laboratory observations.