1.3.6.1.4.1.19376.1.3.10.3.1/static-2016-11-13T142808

Id	1.3.6.1.4.1.19376.1.3.10.3.1	Effective Date	valid from 2016‑11‑13 14:28:08
Status	Draft	Version Label	2.0
Name	AdditionalSpecifiedObservationSection	Display Name	Additional Specified Observation Section
Description	Template 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.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.3.1
Label	PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Classification	CDA Section Level Template
Open/Closed	Open (other than defined elements are allowed)
Associated with	Associated with 1 concept Id Name Data Set psr-data​element-96 Additional Specified Observation APSR 2.0
Used by / Uses	Used by 1 template, Uses 2 templates Used by Template id as Name Version 1.3.6.1.4.1.19376.1.8.1.1.1 Containment Anatomic Pathology Structured Report Content Module (2.0) 2014‑05‑13 11:57:57 Uses Template id as Name Version 1.3.6.1.4.1.19376.1.8.1.4.2 Containment CDA author DYNAMIC 1.3.6.1.4.1.19376.1.8.1.3.6 Containment Problem Organizer (2.0) DYNAMIC
Relationship	Adaptation: 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"/>  <code code="xxxxx-x" codeSystem="2.16.840.1.113883.6.1" displayName="specified observation"/>  <title>ADDITIONAL SPECIFIED OBSERVATION SECTION</title>  <text/>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) -->   </author>  <entry typeCode="COMP" contextConductionInd="true">     <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (dynamic) -->   </entry></section>
Item DT Card Conf Description Label hl7:section 0 … * R PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section @classCode cs 0 … 1 F DOCSECT @moodCode cs 0 … 1 F EVN   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.    Associated with concepts: psr-data​element-96 Additional Specified Observation APSR 2.0 hl7:templateId II 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.10.3.1 hl7:code CE 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section   Constraint The LOINC code SHALL be chosen according the specified observation type @code CONF 1 … 1 F xxxxx-x @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) @displayName 1 … 1 F specified observation @codeSystemName 1 … 1 F LOINC hl7:title ST 1 … 1 R Title of the specified observation PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section   CONF element content shall be "ADDITIONAL SPECIFIED OBSERVATION SECTION"   Example MP observation <text>MOLECULAR PATHOLOGY OBSERVATION SECTION</text> hl7:text SD.TEXT 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section hl7:author 0 … * C Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2 Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author (DYNAMIC) PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section hl7:entry 0 … * R 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 @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true