1.3.6.1.4.1.19376.1.3.10.4.1

Aus Hl7wiki
Wechseln zu: Navigation, Suche
Comments on this page

Template SpecimenProcedureStep

Description

Template CDA Procedure (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF)for Specimen procedure step in APSR2.This entry collects all the information of source, method and result of a specimen procedure from the collection out of the patient through the final product of a stained histologic section or cytologic smear on a glass slide, or a WSI of such a slide. It reflects the workflow and the probe tracking of a pathology laboratory.

Actual version

Id1.3.6.1.4.1.19376.1.3.10.4.1Effective Date valid from 2016‑07‑08 13:20:59

There are versions of templates with this id:
  • SpecimenProcedureStep as of 2016‑07‑08 13:20:59
  • SpecimenProcedureStep as of 2014‑07‑29 16:02:02
StatusKyellow.png DraftVersion Label2.0
NameSpecimenProcedureStepDisplay NameSpecimen Procedure Step
Description
Template CDA Procedure (prototype, directly derived from POCD_RM000040 MIF)
for Specimen procedure step in APSR2.

This entry collects all the information of source, method and result of a specimen procedure from the collection out of the patient through the final product of a stained histologic section or cytologic smear on a glass slide, or a WSI of such a slide. It reflects the workflow and the probe tracking of a pathology laboratory.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.1
LabelPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 4 templates, Uses 8 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.8.1.2.6Link.pngKyellow.png Procedure Steps Section (2.0)2014‑05‑13 19:33:12
1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.3.10.9.44ContainmentKyellow.png CDA Participant (Body) Procedure Steps APSR2 (2.0)2014‑10‑26 17:06:28
1.3.6.1.4.1.19376.1.3.10.9.22ContainmentKyellow.png CDA Supply Container APSR2 (2.0)2016‑07‑29 12:09:33
1.3.6.1.4.1.19376.1.3.1.3ContainmentKgreen.png Specimen Received (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA Reference2005‑09‑07
RelationshipAdaptation: template 2.16.840.1.113883.10.12.306 (2005‑09‑07)
Example
generated example
<procedure negationInd="false" classCode="PROC" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.4.1"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="117617002" displayName="Immunohistochemistry procedure (procedure)" codeSystem="2.16.840.1.113883.5.96">
    <qualifier>
      <name code="246094008 or 246355002" codeSystem="2.16.840.1.113883.6.96" displayName="Component investigated (attribute) or Supporting structure (attribute)"/>      <value code="23307004" codeSystem="2.16.840.1.113883.6.96" displayName="Estrogen receptor (substance)"/>    </qualifier>
  </code>
  <text/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20161110104817"/>  </effectiveTime>
  <targetSiteCode code="441652008" codeSystem="2.16.840.1.113883.6.96" displayName="Formalin-fixed paraffin-embedded tissue specimen (specimen)"/>  <specimen typeCode="SPC">
    <specimenRole classCode="SPEC">
      <id/>    </specimenRole>
  </specimen>
  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->
  </performer>
  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->
  </author>
  <participant>
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.44 'CDA Participant (Body) Procedure Steps APSR2' (2014-10-26T17:06:28) -->
  </participant>
  <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">
    <seperatableInd value="false"/>    <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.22 'CDA Supply Container APSR2' (2016-07-29T12:09:33) -->
  </entryRelationship>
  <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">
    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.3.1.3 'Specimen Received' (2008-08-08T00:00:00) -->
  </entryRelationship>
  <entryRelationship negationInd="false" typeCode="REFR" inversionInd="false" contextConductionInd="true">
    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.4.1 'Specimen Procedure Step' (2016-07-08T13:20:59) -->
  </entryRelationship>
  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
  </reference>
</procedure>
ItemDTCardConfDescriptionLabel
hl7:procedure
0 … *RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treetree.png@classCode
cs1 … 1FPROC
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.4.1
Treetree.pnghl7:id
II0 … *RProcedure ID, coming from the LIS.
May be the target (referenced) ID for the child procedure.
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treetree.pnghl7:code
CD (extensible)1 … 1MCoded procedurePaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 Constraintfor specimen collection procedure codes for targetSite or SNOMED CT have to be used, for specimen processing (down step the procedures) SNOMED CT is preferred, DICOM could be used if available
 CONF
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.10 Specimen Collection and Processing (2016‑05‑31 15:09:59)
 Example
for use case #1, specimen collection
<code code="122548005" codeSystem="2.16.840.1.113883.6.96" displayName="Biopsy of breast (procedure)" codeSystemName="SNOMED-CT"/>
 Example
for use case #1, grossing & embedding
<code code="40923002" codeSystem="2.16.840.1.113883.6.96" displayName="Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)"/>
 Example
for use case #1, sectioning & immunostaining
<code code="117617002" codeSystem="2.16.840.1.113883.6.96" displayName="Immunohistochemistry procedure (procedure)"/>
Treeblank.pngTreetree.pnghl7:qualifier
CR (extensible)0 … *CQualifier for staining or other procedures which don´t have values in the vocabulary used.
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 ConstraintUsed only in staining and other procedures without values in SCT or LOINC or DICOM vocabulary, e.g. immune stains
 Example
for use case #1, grossing & embedding
<qualifier>
  <name code="246355002" displayName="Supporting structure (attribute)" codeSystem="2.16.840.1.113883.6.96"/>  <value code="702941008" displayName="Paraffin embedding (qualifier value)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/></qualifier>
 Example
for use case #1, Estrogen receptor staining
<qualifier>
  <name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/>  <value code="23307004" displayName="Estrogen receptor (substance)" codeSystem="2.16.840.1.113883.6.96"/></qualifier>
 Example
for use case #1, ISH Her-2-neu staining
<qualifier>
  <name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/>  <value code="164870" displayName="ONCOGENE ERBB2" codeSystem="2.16.840.1.113883.6.174" codeSystemName="OMIM"/></qualifier>
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV (extensible)1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs0 … 1F246094008_or_246355002
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid0 … 1F2.16.840.1.113883.6.96
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st0 … 1FComponent investigated (attribute) or Supporting structure (attribute)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD (extensible)1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs1 … 1R
 CONF
@code shall be "<<105590001 | Substance (substance) |"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SNOMED-CT"
@displayName shall be "values from substance axis, e.g. Estrogen receptor"
or
@code shall be "values from G axis"
@codeSystem shall be "2.16.840.1.113883.6.174"
@codeSystemName shall be "OMIM"
@displayName shall be "values from G axis, e.g. erb-b2"
or
@code shall be "<<272394005 | Technique (qualifier value) |"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SNOMED-CT"
@displayName shall be "values from technique axis, e.g. Paraffin embedded (qualifier)"
Treetree.pnghl7:text
ED0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 Example
specimen collection procedure
<text>ULTRASOUND GUIDED NEEDLE CORE BIOPSY</text>
 Example
specimen processing procedure
<text>CUTTING A SLIDE FROM A PARAFFIN BLOCK</text>
Treetree.pnghl7:statusCode
CS (required)0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treetree.pnghl7:approachSiteCode
CD (extensible)0 … 1RApproach site in specimen collectionPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreetree.png@code
CONF0 … 1Fany_code
Treeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.5.1052 (Act Site)
Treeblank.pngTreetree.png@codeSystemName
0 … 1Fany_code
Treeblank.pngTreetree.png@displayName
0 … 1FActSite
Treetree.pnghl7:target​Site​Code
CD (extensible)0 … 1RTarget site in body or relative parent relationship in case of  specimen processingPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 CONF
@code shall be "<<123037004 | Body structure (body structure) |"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SCT"
@displayName shall be "all children of Body structure (body structure)"
or
@code shall be "any_code"
@codeSystem shall be "2.16.840.1.113883.5.1052"
@codeSystemName shall be "ActSite"
@displayName shall be "any_code"
or
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.9 Procedure Site (2016‑06‑01 18:46:15)
 Example
for use case #1, specimen collection
<targetSiteCode code="110497008" displayName="Lower outer quadrant of right breast (body structure)" codeSystem="2.16.840.1.113883.6.96"/>
 Example
for use case #1, grossing & embedding
<targetSiteCode code="309050000" displayName="Body substance sample" codeSystem="2.16.840.1.113883.6.96"/>
Treeblank.pngTreetree.pnghl7:qualifier
CR (extensible)0 … *Coptional qualifiers for specifying body structures or / and lateralityPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 Example
for use case #1, (optional) specification of body structure for specimen collection
<qualifier>
  <name code="118169006" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen source topography (attribute)" codeSystemName="SNOMED-CT"/>  <value code="255495000" codeSystem="2.16.840.1.113883.6.96" displayName="Right lower quadrant (qualifier value)" codeSystemName="SNOMED-CT"/></qualifier>
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV (extensible)1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st0 … 1FSpecimen source topography
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F2.16.840.1.113883.6.96
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1F118169006
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD (extensible)0 … *RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF0 … 1 @code shall be out of choice:
  • <<272099008
  • Descriptor (qualifier value)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.6.96 (SNOMED Clinical Terms)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
0 … 1FSCT
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
0 … 1Fall children of "Descriptor, qualifier values", e.g. right lower quadrantt
Treetree.pnghl7:methodCode
CD (extensible)0 … *RIdentifies the technique used to perform a procedure
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreetree.png@codeSystem
cs1 … 1F2.16.840.1.113883.5.1065
Included0 … 1R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Parent specimen with parent ID
 Example
for use case #1, parent specimen ID in grossing & embedding
<specimen typeCode="SPC">
  <specimenRole classCode="SPEC">
    <!-- Parent specimen ID -->
    <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008"/>  </specimenRole>
</specimen>
Treetree.pnghl7:specimen
0 … 1RRequired in XD-LAB when more than one specimen is documented at this level. Always required in APSR.
PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreetree.png@typeCode
cs0 … 1FSPC
Treeblank.pngTreetree.pnghl7:specimenRole
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FSPEC
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treetree.pnghl7:performer
0 … 1RContains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
Treetree.pnghl7:author
0 … *CContains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.png where [hl7:author [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.2']]]
Treetree.pnghl7:participant
1 … *MOne or more specimen (with additives), which participates as product of the procedure
Contains 1.3.6.1.4.1.19376.1.3.10.9.44 CDA Participant (Body) Procedure Steps APSR2 (2014‑10‑26 17:06:28)
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.png where [not(@nullFlavor)]
Treetree.pnghl7:entryRelationship
0 … *RArtificial material (manufactured product) which
   containes 
the specimen
Contains 1.3.6.1.4.1.19376.1.3.10.9.22 CDA Supply Container APSR2 (2016‑07‑29 12:09:33)
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.png where [@typeCode='COMP'] [hl7:supply [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.22']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
 Constraintfor manufactured product


classCode = MANU

for DrugOrOtherMaterial
classCode = MMAT
code from MaterialEntityClassType


Treetree.pnghl7:entryRelationship
0 … 1RSpecimen arrival in Lab
Contains 1.3.6.1.4.1.19376.1.3.1.3 Specimen Received (2008‑08‑08)
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.png where [@typeCode='COMP'] [hl7:act [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.1.3']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:entryRelationship
0 … *RReferencing mechanism to the ID of the child procedures, giving a lis of child procedure IDs
Contains 1.3.6.1.4.1.19376.1.3.10.4.1 Specimen Procedure Step (2016‑07‑08 13:20:59)
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.png where [@typeCode='REFR'] [hl7:procedure [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.4.1']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFR
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
 Constraintcontains only ID of the child procedure, which is fully described in a dedicated entry further down in the Procedure step section.
Treetree.pnghl7:reference
0 … *RReference to an external document, or to external procedures, e.g. concerning molecular pathology or  genetic testing report

Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

List of all versions of this template