1.3.6.1.4.1.19376.1.8.1.2.2/static-2014-05-13T192916

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Id1.3.6.1.4.1.19376.1.8.1.2.2Effective Date valid from 2014‑05‑13 19:29:16
StatusKyellow.png DraftVersion Label2.0
NameIntraoperativeObservationSectionDisplay NameIntraoperative Observation Section
DescriptionThe Intraoperative Observation section contains an intraoperative diagnosis for each specimen examined, the specimen identification and description, intraoperative observation procedure description (frozen section, gross examination, intraoperative cytology) and derived specimen dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, and electron microscopy).
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.2
LabelPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
ClassificationCDA Section Level Template
Open/ClosedClosed (only defined elements are allowed)
Associated with
Associated with 2 concepts
IdNameData Set
psr-data​element-44Intraoperative observation APSR 2.0
psr-data​element-64intraoperative observation textAPSR 2.0
Used by / Uses
Used by 1 template, Uses 2 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
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA authorDYNAMIC
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example
generated example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.2"/>  <code code="83321-0" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report intraoperative observation in Specimen Document"/>  <title>Intraoperative observation</title>  <text/>  <languageCode/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) 0..* C -->
  <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 … 1RPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
Treetree.png@classCode
cs1 … 1FDOCSECT
Treetree.png@moodCode
cs1 … 1FEVN
 Constraint

This section SHALL contain a narrative block, represented by a text element, 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 observed. These entries provide the machine-readable data corresponding to the narrative block.

This section does not contain any subsection.

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

 Target.pngAssociated with concepts:
psr-data​element-44Intraoperative observation APSR 2.0
Treetree.pnghl7:templateId
II1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.2
Treetree.pnghl7:code
CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
 Constraint
Treeblank.pngTreetree.png@code
CONF1 … 1F83321-0
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@displayName
1 … 1FPathology report intraoperative observation in Specimen Document
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treetree.pnghl7:title
ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
 CONF
element content shall be "Intraoperative observation"
Treetree.pnghl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
 Target.pngAssociated with concepts:
psr-data​element-64intraoperative observation textAPSR 2.0
 Example
Intraoperative observation
<text>Frozen section diagnosis of infiltrating duct carcinoma, left breast</text>
Treetree.pnghl7:language​Code
CS0 … 1PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author (DYNAMIC)
Author
Source: PaLM Suppl. APSR 2.0-3: 6.2.6.2
Treetree.pnghl7:author
0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.png@typeCode
cs0 … 1FAUT
Treeblank.pngTreetree.png@context​Control​Code
cs0 … 1FOP
 Target.pngAssociated with concepts:
psr-data​element-4PathologistAPSR 2.0
psr-data​element-79DeviceAPSR 2.0
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor>
</author>
Treeblank.pngTreetree.pnghl7:functionCode
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
Treeblank.pngTreetree.pnghl7:time
TS.​DATE.​MIN1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 Example
author is a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>
</representedOrganization>
Included from 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treetree.pnghl7:entry
0 … *RSource: PAT TF-3:6.2.6.8

Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (DYNAMIC)
PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue