1.3.6.1.4.1.19376.1.3.10.3.1/static-2016-11-13T142808: Unterschied zwischen den Versionen

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<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.3.1</td><th style="width: 20em; text-align: left;">Effective Date</th><td style="text-align: left;"> valid from 2016‑11‑13 14:28:08</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|16px]] Draft</td><th style="width: 20em; text-align: left;">Version Label</th><td style="text-align: left;">2.0</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">AdditionalSpecifiedObservationSection</td><th style="width: 20em; text-align: left;">Display Name</th><td style="text-align: left;">Additional Specified Observation Section</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Description</th><td style="text-align: left;" colspan="3">Template CDA Section (prototype, directly derived from POCD_RM000040 MIF)<br /><br />The Additional Specified Observation section includes additional pathologic finding(s) and the results of ancillary study(yes) with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken. The only entry for this section is the Problem Organizer Entry module.<br /></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Context</th><td style="text-align: left;" colspan="3">Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.3.1</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Label</th><td style="text-align: left;" colspan="3">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section<br /></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Classification</th><td style="text-align: left;" colspan="3">CDA Section Level Template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Open/Closed</th><td style="text-align: left;" colspan="3">Open (other than defined elements are allowed)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Associated with</th><td style="text-align: left;" colspan="3"><table class="treetable" id="assocsTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Associated with 1 concept</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Id</th><th style="width: 60%; text-align: left;">Name</th><th style="width: 20%; text-align: left;">Data Set</th></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;"><span style="color: grey;">psr-data&#8203;element-</span>96</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Observation / ">Additional Specified Observation</td><td style="text-align: left; vertical-align: top;">APSR 2.0</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Used by / Uses</th><td style="text-align: left;" colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Used by 1 template, Uses 3 templates</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Used by Template id</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.1.1</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Anatomic Pathology Structured Report (2.0)</td><td style="text-align: left;">2014‑05‑13 11:57:57</td></tr><tr><th style="width: 20%; text-align: left;">Uses Template id</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">2.16.840.1.113883.10.12.318</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|16px]] CDA Author (Body)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.6</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|16px]] CDA Informant(Header&amp;Body) APSR2 (2.0)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.3.6</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Problem Organizer (2.0)</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Relationship</th><td style="text-align: left;" colspan="3">Adaptation: template 2.16.840.1.113883.10.12.201 (<i>2005‑09‑07</i>)</td></tr><tr class="explabel" style="vertical-align: top;"><td style="width: 20em; text-align: left;">Example</td><td colspan="3" class="explabelblue"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">generated example</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">section</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">DOCSECT</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.3.10.3.1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.3.999</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">--example only--</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">57025-9</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Data Criteria section</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">title</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">languageCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">aa</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">author</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">author</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">informant</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&amp;Body) APSR2' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">informant</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entry</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span> <span class="ppattribute">contextConductionInd</span><span class="ppsign">="</span><span class="ppcontent">true</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entry</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Card</th><th style="width: 2em; text-align: left;">Conf</th><th style="text-align: left;">Description</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:section<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">DOCSECT</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@moodCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td style="vertical-align: top; text-align: left;">[[File:Target.png|16px]]</td><td colspan="4" style="background-color: #F4FFF4;" class="tabtab">Associated with concepts:<table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span style="color: grey;">psr-data&#8203;element-</span>96</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Observation / ">Additional Specified Observation</td><td style="width: 35%; vertical-align: top;">APSR 2.0</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.3.6.1.4.1.19376.1.3.10.3.1</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:code<br /></strong></tt></td></tr></table></td><td><strong>CE</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4">The LOINC code SHALL be chosen according the specified observation type</td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10871 <i>DocumentSectionType </i>(DYNAMIC)</td></tr><tr style="vertical-align: top;"><td>or</td></tr><tr style="vertical-align: top;"><td>@code shall be "xxxxx-x"</td></tr><tr style="vertical-align: top;"><td>@codeSystem shall be "2.16.840.1.113883.6.1"</td></tr><tr style="vertical-align: top;"><td>@displayName shall be "specified observation"</td></tr><tr style="vertical-align: top;"><td>@codeSystemName shall be "LOINC"</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:title<br /></strong></tt></td></tr></table></td><td><strong>ST</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td>Title of the specified observation</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr class="explabel" style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelblue"><div>MP observation </div><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><span class="pptext">Molecular Pathology observation</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:text<br /></strong></tt></td></tr></table></td><td><strong>SD.TEXT</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:language&#8203;Code<br /></strong></tt></td></tr></table></td><td><strong>CS</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 <i>HumanLanguage </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:author<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td>Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM Suppl. APSR 2.0-3: 6.3.6.2</span><br /><br />Contains 2.16.840.1.113883.10.12.318 <i>CDA Author (Body)</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:informant<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td>Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM Suppl. APSR 2.0-3: 6.3.6.5</span><br /><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.6 <i>CDA Informant(Header&amp;Body) APSR2</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entry<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td>Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM Suppl. APSR 2.0-3: 6.2.5.2</span><br /><br />Contains 1.3.6.1.4.1.19376.1.8.1.3.6 <i>Problem Organizer</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@context&#8203;Conduction&#8203;Ind<br /></strong></tt></td></tr></table></td><td>bl</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">true</td></tr></table></td></tr></table>
+
<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.3.1</td><th style="width: 20em; text-align: left;">Effective Date</th><td style="text-align: left;"> valid from 2016‑11‑13 14:28:08</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|16px]] Draft</td><th style="width: 20em; text-align: left;">Version Label</th><td style="text-align: left;">2.0</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">AdditionalSpecifiedObservationSection</td><th style="width: 20em; text-align: left;">Display Name</th><td style="text-align: left;">Additional Specified Observation Section</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Description</th><td style="text-align: left;" colspan="3">Template CDA Section (prototype, directly derived from POCD_RM000040 MIF)<br /><br />The Additional Specified Observation section includes additional pathologic finding(s) and the results of ancillary study(yes) with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken. The only entry for this section is the Problem Organizer Entry module.<br /></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Context</th><td style="text-align: left;" colspan="3">Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.3.1</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Label</th><td style="text-align: left;" colspan="3">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section<br /></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Classification</th><td style="text-align: left;" colspan="3">CDA Section Level Template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Open/Closed</th><td style="text-align: left;" colspan="3">Open (other than defined elements are allowed)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Associated with</th><td style="text-align: left;" colspan="3"><table class="treetable" id="assocsTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Associated with 1 concept</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Id</th><th style="width: 60%; text-align: left;">Name</th><th style="width: 20%; text-align: left;">Data Set</th></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;"><span style="color: grey;">psr-data&#8203;element-</span>96</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Observation / ">Additional Specified Observation</td><td style="text-align: left; vertical-align: top;">APSR 2.0</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Used by / Uses</th><td style="text-align: left;" colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Used by 1 template, Uses 3 templates</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Used by Template id</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.1.1</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Anatomic Pathology Structured Report (2.0)</td><td style="text-align: left;">2014‑05‑13 11:57:57</td></tr><tr><th style="width: 20%; text-align: left;">Uses Template id</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">2.16.840.1.113883.10.12.318</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|16px]] CDA Author (Body)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.6</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|16px]] CDA Informant(Header&amp;Body) APSR2 (2.0)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.3.6</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Problem Organizer (2.0)</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Relationship</th><td style="text-align: left;" colspan="3">Adaptation: template 2.16.840.1.113883.10.12.201 (<i>2005‑09‑07</i>)</td></tr><tr class="explabel" style="vertical-align: top;"><td style="width: 20em; text-align: left;">Example</td><td colspan="3" class="explabelgreen"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">generated example</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">section</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">DOCSECT</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.3.10.3.1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.3.999</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">--example only--</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">57025-9</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Data Criteria section</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">title</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">languageCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">aa</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">author</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">author</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">informant</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&amp;Body) APSR2' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">informant</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entry</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span> <span class="ppattribute">contextConductionInd</span><span class="ppsign">="</span><span class="ppcontent">true</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entry</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Card</th><th style="width: 2em; text-align: left;">Conf</th><th style="text-align: left;">Description</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:section<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">DOCSECT</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@moodCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><p class="TableEntry" style="margin: 6pt 3.7pt 0.0001pt 0cm;"><span lang="EN-US">This section SHALL contain a code element populated with these attributes:<span style="font-size: 12pt;"></span></span></p><p class="TableEntry" style="margin: 0cm 3.7pt 0.0001pt 36pt;"><span lang="EN-US">@code</span><span lang="EN-US">="xxxxx-x" (specific for the additional specified observation)</span></p><p class="TableEntry" style="margin: 0cm 3.7pt 0.0001pt 36pt;"><span lang="EN-US">@codeSystem</span><span lang="EN-US">="2.16.840.1.113883.6.1" </span></p><p class="TableEntry" style="margin: 0cm 3.7pt 0.0001pt 36pt;"><span lang="EN-US">@displayName</span><span lang="EN-US">="Pathology report yyyyy (specific) observation"  <span style="font-size: 12pt;"></span></span></p><p class="MsoBodyText"><span lang="EN-US">This section SHALL contain a narrative block, represented by a <i>text</i>element, which renders the information to the human reader.</span></p><p class="MsoBodyText"><span lang="EN-US">The section SHOULD contain as many Problem Organizer <i>entry</i> elements as there are problems or groups thereof to be described. These entries provide the machine-readable data corresponding to the narrative block.</span></p><p class="MsoBodyText"><span lang="EN-US">This section SHOULD contain <i>author</i> elements in case the authors of this section differ from those declared at a higher level in the document.</span></p><p class="MsoBodyText"><span lang="EN-US">This section does not contain any subsections. </span></p></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td style="vertical-align: top; text-align: left;">[[File:Target.png|16px]]</td><td colspan="4" style="background-color: #F4FFF4;" class="tabtab">Associated with concepts:<table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span style="color: grey;">psr-data&#8203;element-</span>96</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Observation / ">Additional Specified Observation</td><td style="width: 35%; vertical-align: top;">APSR 2.0</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.3.6.1.4.1.19376.1.3.10.3.1</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:code<br /></strong></tt></td></tr></table></td><td><strong>CE</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4">The LOINC code SHALL be chosen according the specified observation type</td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10871 <i>DocumentSectionType </i>(DYNAMIC)</td></tr><tr style="vertical-align: top;"><td>or</td></tr><tr style="vertical-align: top;"><td>@code shall be "xxxxx-x"</td></tr><tr style="vertical-align: top;"><td>@codeSystem shall be "2.16.840.1.113883.6.1"</td></tr><tr style="vertical-align: top;"><td>@displayName shall be "specified observation"</td></tr><tr style="vertical-align: top;"><td>@codeSystemName shall be "LOINC"</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:title<br /></strong></tt></td></tr></table></td><td><strong>ST</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td>Title of the specified observation</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr class="explabel" style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelgreen"><div>MP observation </div><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><span class="pptext">Molecular Pathology observation</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:text<br /></strong></tt></td></tr></table></td><td><strong>SD.TEXT</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:language&#8203;Code<br /></strong></tt></td></tr></table></td><td><strong>CS</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 <i>HumanLanguage </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:author<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td>Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM Suppl. APSR 2.0-3: 6.3.6.2</span><br /><br />Contains 2.16.840.1.113883.10.12.318 <i>CDA Author (Body)</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:informant<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td>Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM Suppl. APSR 2.0-3: 6.3.6.5</span><br /><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.6 <i>CDA Informant(Header&amp;Body) APSR2</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entry<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td>Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM Suppl. APSR 2.0-3: 6.2.5.2</span><br /><br />Contains 1.3.6.1.4.1.19376.1.8.1.3.6 <i>Problem Organizer</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@context&#8203;Conduction&#8203;Ind<br /></strong></tt></td></tr></table></td><td>bl</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">true</td></tr></table></td></tr></table>

Version vom 4. Februar 2017, 10:45 Uhr

Id1.3.6.1.4.1.19376.1.3.10.3.1Effective Date valid from 2016‑11‑13 14:28:08
StatusKyellow.png DraftVersion Label2.0
NameAdditionalSpecifiedObservationSectionDisplay NameAdditional Specified Observation Section
DescriptionTemplate CDA Section (prototype, directly derived from POCD_RM000040 MIF)

The Additional Specified Observation section includes additional pathologic finding(s) and the results of ancillary study(yes) with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken. The only entry for this section is the Problem Organizer Entry module.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.3.1
LabelPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 1 concept
IdNameData Set
psr-data​element-96Additional Specified ObservationAPSR 2.0
Used by / Uses
Used by 1 template, Uses 3 templates
Used by Template id as NameVersion
1.3.6.1.4.1.19376.1.8.1.1.1ContainmentKyellow.png Anatomic Pathology Structured Report (2.0)2014‑05‑13 11:57:57
Uses Template id as NameVersion
2.16.840.1.113883.10.12.318ContainmentKgreen.png CDA Author (Body)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example
generated example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.3.1"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="57025-9" displayName="Data Criteria section" codeSystem="2.16.840.1.113883.6.1"/>  <title/>  <text/>  <languageCode code="aa"/>  <author>
    <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' (dynamic) -->
  </author>
  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (dynamic) -->
  </informant>
  <entry typeCode="COMP" contextConductionInd="true">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (dynamic) -->
  </entry>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … *RPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.png@moodCode
cs0 … 1FEVN
 Constraint

This section SHALL contain a code element populated with these attributes:

@code="xxxxx-x" (specific for the additional specified observation)

@codeSystem="2.16.840.1.113883.6.1" 

@displayName="Pathology report yyyyy (specific) observation"  

This section SHALL contain a narrative block, represented by a textelement, which renders the information to the human reader.

The section SHOULD contain as many Problem Organizer entry elements as there are problems or groups thereof to be described. These entries provide the machine-readable data corresponding to the narrative block.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

This section does not contain any subsections. 

 Target.pngAssociated with concepts:
psr-data​element-96Additional Specified ObservationAPSR 2.0
Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.3.1
Treetree.pnghl7:id
II0 … 1PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Treetree.pnghl7:code
CE1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
 ConstraintThe LOINC code SHALL be chosen according the specified observation type
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10871 DocumentSectionType (DYNAMIC)
or
@code shall be "xxxxx-x"
@codeSystem shall be "2.16.840.1.113883.6.1"
@displayName shall be "specified observation"
@codeSystemName shall be "LOINC"
Treetree.pnghl7:title
ST1 … 1RTitle of the specified observationPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
 Example
MP observation
<text>Molecular Pathology observation</text>
Treetree.pnghl7:text
SD.TEXT1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Treetree.pnghl7:language​Code
CS0 … 1PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
Treetree.pnghl7:author
0 … *Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2

Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)
PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Treetree.pnghl7:informant
0 … *Source: PaLM Suppl. APSR 2.0-3: 6.3.6.5

Contains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (DYNAMIC)
PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Treetree.pnghl7:entry
0 … *Source: PaLM Suppl. APSR 2.0-3: 6.2.5.2

Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (DYNAMIC)
PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue