2.16.840.1.113883.2.6.60.6.10.4

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Template DiagnosticConclusionSection

Beschreibung

The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.

Aktuelle Version

Id2.16.840.1.113883.2.6.60.6.10.4Gültigkeit gültig ab 2014‑05‑13 19:31:26
StatusKyellow.png EntwurfVersions-Label
NameDiagnosticConclusionSectionAnzeigenameDiagnostic Conclusion Section
Beschreibung

The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.

KontextElternknoten des Template-Element mit Id 2.16.840.1.113883.2.6.60.6.10.4
KlassifikationCDA Section level template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Assoziiert mit
Assoziiert mit 1 Konzept
IdNameDatensatz
psr-data​element-3PSR
Benutzt von / Benutzt
Benutzt von 1 Template, Benutzt 2 Templates
Benutzt von Template-Id als NameVersion
2.16.840.1.113883.2.6.60.6.10.1ContainmentPathology Structured Report2014‑05‑13 11:57:57
Benutzt Template-Id als NameVersion
1.2.276.0.76.10.90025ContainmentCDAAuthorBodyDYNAMIC
2.16.840.1.113883.2.6.60.6.10.34ContainmentProblemOrganizerDYNAMIC
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Beispiel
Beispiel
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="2.16.840.1.113883.2.6.60.6.10.4"/>
  <id root="1.2.3.999" extension="--example only--"/>
  <code code="22637-3" codeSystem="2.16.840.1.113883.6.1" displayName="'Pathology report diagnosis"/>
  <title>Diagnostic conclusion</title>  <text/>
  <author>
    <!-- template CDAAuthorBody (dynamic) -->
  </author>
  <entry>
    <!-- template 2.16.840.1.113883.2.6.60.6.10.9 (dynamic) -->
  </entry>
</section>
ItemDTKardKonfBeschreibungLabel
hl7:section
1 … 1M(DiagnosticConclusionSection)
Treetree.png@classCode
0 … 1FDOCSECT
Treetree.png@moodCode
0 … 1FEVN
 Target.pngZiel der Konzept Id(s):
psr-data​element-3PSR
Treetree.pnghl7:templateId
II1 … 1R(DiagnosticConclusionSection)
Treeblank.pngTreetree.png@root
1 … 1F2.16.840.1.113883.2.6.60.6.10.4
Treetree.pnghl7:id
II0 … 1(DiagnosticConclusionSection)
Treetree.pnghl7:code
CE0 … 1(DiagnosticConclusionSection)
Treeblank.pngTreetree.png@code
1 … 1F22637-3
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@displayName
1 … 1F'Pathology report diagnosis
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treetree.pnghl7:title
ST1 … 1M(DiagnosticConclusionSection)
 CONF
Elementinhalt muss "Diagnostic conclusion" sein
Treetree.pnghl7:text
SD.TEXT1 … 1M(DiagnosticConclusionSection)
 Beispiel
Diagnosis
<text> Invasive breast cancer, no special type TNM: pT1c pN0(0/3sn) L0 V0 R0 G2 ICD-O-3: 8500/3 </text>
Treetree.pnghl7:author
0 … *Beinhaltet 1.2.276.0.76.10.90025 CDA Author (Body) (DYNAMIC)(DiagnosticConclusionSection)
Treetree.pnghl7:entry
1 … *RBeinhaltet 2.16.840.1.113883.2.6.60.6.10.34 Problem Organizer (DYNAMIC)(DiagnosticConclusionSection)

Zusammenstellung aller Versionen dieses Templates