1.3.6.1.4.1.19376.1.8.1.2.4/static-2014-05-13T142517

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Id1.3.6.1.4.1.19376.1.8.1.2.4Effective Date valid from 2014‑05‑13 14:25:17
StatusKyellow.png DraftVersion Label2.0
NameMicroscopySectionDisplay NameMicroscopic Observation Section
Description
The Microscopic Observation section contains optionally the histopathologic findings of the case and of all of the derived specimens. This section should be used to record the results of histochemical and immunohistochemical stains and of image-based molecular methods.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.4
LabelPaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
ClassificationCDA Section Level Template
Open/ClosedClosed (only defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 2 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.1.1ContainmentKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA author IHEDYNAMIC
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
Example
<section>
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.4"/>  <code code="22635-7" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report microscopic observation"/>  <title>MICROSCOPIC OBSERVATION SECTION</title>  <text/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) 0..* C -->
  <entry>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (dynamic) -->
  </entry>
  <component typeCode="COMP">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (dynamic) -->
  </component>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … 1RPaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
 Constraint

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

@code="22635-7"

@codeSystem="2.16.840.1.113883.6.1"

@displayName="Pathology report microscopic observation" 

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 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. 

Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.4
Treetree.pnghl7:code
CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
Treeblank.pngTreetree.png@code
CONF1 … 1F22635-7
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 microscopic observation
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treetree.pnghl7:title
ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
 CONF
element content shall be "MICROSCOPIC OBSERVATION SECTION"
 Example<title>MICROSCOPIC OBSERVATION SECTION</title>
Treetree.pnghl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
 Example<text> Sections of part #1 confirm frozen section diagnosis of infiltrating duct carcinoma. It is to be noted that the tumor cells show considerable pleomorphism, and mitotic figures are frequent (as many as 4 per high power field). Total size of primary tumor is estimated to be 3cm in greatest dimension. Many foci of calcification are present within the tumor. Part #2 consists of fibrofatty tissue and includes 18 lymph nodes. All lymph nodes are free of disease with the exception of one lymph node, which contains several micrometastases. </text>
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (DYNAMIC)
Author

Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2
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
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor>
</author>
Treeblank.pngTreetree.pnghl7:functionCode
CE CWE0 … 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 (2014‑03‑26)
Treeblank.pngTreetree.pnghl7:templateId
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
Treeblank.pngTreetree.pnghl7:time
TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:assignedAuthor
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1
The author is either an assigned person or an authoring device.
Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC)
The name(s) SHALL be given.
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
0 … 1CPaLM 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
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 Example
represented organization for author as a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>
</representedOrganization>
Included0 … 1 from 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC)
The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … 1PaLM 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 … *RProblem organizer entry

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: 6.3.4.4 Microscopic observation section
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue