1.3.6.1.4.1.19376.1.8.1.1.1/static-2014-05-13T115757

Id	1.3.6.1.4.1.19376.1.8.1.1.1	Effective Date	valid from 2014‑05‑13 11:57:57
Status	Draft	Version Label	2.0
Name	AnatomicPathologyStructuredReportContentModule	Display Name	Anatomic Pathology Structured Report Content Module
Description	This document content module represents the generic set of constraints applied to any structured report for surgical pathology in all fields of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as for Cytopathology. This document content module is identified by templateId 1.3.6.1.4.1.19376.1.8.1.1.1 The body of this Document Content Module specifies a common hierarchy of sections and entries depicted by figure 10.4.1-1 in Volume 1 IHE_PaLM_Suppl_APSR 2.0. The only mandatory section is the Diagnostic Conclusion Section. And the only mandatory entry is the Problem Organizer Entry below this section.  This Document Content Module defines the base set of constraints that apply to all AP structured report, related to any kind of lesion or diagnostic problem. In other words, this is the generic template for any AP structured report.
Context	Pathname //
Label	PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Classification	CDA Document Level Template
Open/Closed	Closed (only defined elements are allowed)
Associated with	Associated with 4 concepts Id Name Data Set psr-data​element-58 Anatomic Pathology Structured Report APSR 2.0 psr-data​element-50 Accession Number APSR 2.0 psr-data​element-32 Case APSR 2.0 psr-data​element-27 (administrative) Gender APSR 2.0
Used by / Uses	Used by 0 templates, Uses 21 templates Uses Template id as Name Version 1.3.6.1.4.1.19376.1.8.1.4.6 Containment CDA Informant(Header&Body) APSR2 (2.0) DYNAMIC 2.16.840.1.113883.10.12.101 Include CDA recordTarget DYNAMIC 1.3.6.1.4.1.19376.1.8.1.4.2 Include CDA author DYNAMIC 2.16.840.1.113883.10.12.103 Include CDA dataEnterer DYNAMIC 2.16.840.1.113883.10.12.104 Include CDA custodian DYNAMIC 1.3.6.1.4.1.19376.1.3.3.1.4 Include Information Recipient (2008) 2008‑08‑08 2.16.840.1.113883.2.6.60.6.10.49 Include CDA legalAuthenticator IHE DYNAMIC 1.3.6.1.4.1.19376.1.8.1.4.3 Include CDA authenticator IHE DYNAMIC 1.3.6.1.4.1.19376.1.3.3.1.6 Include Ordering Provider (2008) 2008‑08‑08 1.3.6.1.4.1.19376.1.8.1.4.1 Include CDA Participant Specimen Collector DYNAMIC 2.16.840.1.113883.10.12.109 Include CDA inFulfillmentOf DYNAMIC 1.3.6.1.4.1.19376.1.3.1.9999.10.9.15 Include DocumentationOf Laboratory Performer (2016) DYNAMIC 1.3.6.1.4.1.19376.1.3.1.9999.10.9.16 Include RelatedDocument Parent Document (2016) DYNAMIC 2.16.840.1.113883.10.12.113 Include CDA componentOf DYNAMIC 1.3.6.1.4.1.19376.1.8.1.2.1 Containment Clinical Information Section (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.2.2 Containment Intraoperative Observation Section (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.2.3 Containment Macroscopic Observation Section (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.2.4 Containment Microscopic Observation Section (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.3.10.3.1 Containment Additional Specified Observation Section (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.2.5 Containment Diagnostic Conclusion Section (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.2.6 Containment Procedure Steps Section (2.0) DYNAMIC
Relationship	Specialization: template 2.16.840.1.113883.10.12.1 (2005‑09‑07)
Example	generated example <ClinicalDocument classCode="DOCCLIN" moodCode="EVN">   <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>  <templateId root="1.3.6.1.4.1.19376.1.8.1.1.1"/>  <id extension="999-1" root="1.3.6.1.4.1.19376.1.8.9"/>  <code code="11526-1" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology Study"/>  <title>Anatomic Pathology Structured Report</title>  <effectiveTime value="20161202090407"/>  <confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25"/>  <languageCode/>  <setId extension="999" root="1.3.6.1.4.1.19376.1.8.9"/>  <versionNumber value="1"/>  <informant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Body) APSR2' (dynamic) -->   </informant>  <!-- include template 2.16.840.1.113883.10.12.101 'CDA recordTarget' (dynamic) 1..1 M -->   <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) 1..* M -->   <!-- include template 2.16.840.1.113883.10.12.103 'CDA dataEnterer' (dynamic) 0..* O -->   <!-- include template 2.16.840.1.113883.10.12.104 'CDA custodian' (dynamic) 1..1 M -->   <!-- include template 1.3.6.1.4.1.19376.1.3.3.1.4 'CDA informationRecipient IHE' (dynamic) 0..* O -->   <!-- include template 2.16.840.1.113883.10.12.106 'CDA legalAuthenticator' (dynamic) 1..1 M -->   <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.3 'CDA authenticator IHE' (dynamic) 0..* O -->   <!-- include template 1.3.6.1.4.1.19376.1.3.3.1.6 'CDA Participant Ordering Provider' (dynamic) 0..1 R -->   <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.1 'CDA participant specimen collector' (dynamic) 0..* R -->   <!-- include template 2.16.840.1.113883.10.12.109 'CDA inFulfillmentOf' (dynamic) 0..1 R -->   <!-- include template 1.3.6.1.4.1.19376.1.3.1.9999.10.9.15 'DocumentationOf Laboratory Performer' (dynamic) 0..1 R -->   <!-- include template 1.3.6.1.4.1.19376.1.3.1.9999.10.9.16 'RelatedDocument Parent Document' (dynamic) 0..1 R -->   <!-- include template 2.16.840.1.113883.10.12.113 'CDA componentOf' (dynamic) 0..1 R -->   <component typeCode="COMP" contextConductionInd="true">     <structuredBody classCode="DOCBODY" moodCode="EVN">       <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.1 'Clinical Information Section' (dynamic) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.2 'Intraoperative Observation Section' (dynamic) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.3 'Macroscopic Observation Section' (dynamic) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.4 'Microscopic Observation Section' (dynamic) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.3.10.3.1 'Additionally Specified Observation Section' (dynamic) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.5 'Diagnostic Conclusion Section' (dynamic) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.6 'Procedure Steps Section' (dynamic) -->       </component>    </structuredBody>  </component></ClinicalDocument>
Item DT Card Conf Description Label hl7:ClinicalDocument 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode cs 0 … 1 F DOCCLIN @moodCode cs 0 … 1 F EVN   Associated with concepts: psr-data​element-58 Anatomic Pathology Structured Report APSR 2.0 psr-data​element-27 (administrative) Gender APSR 2.0 hl7:typeId II 1 … 1 M CDA conformance PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @root uid 1 … 1 F 2.16.840.1.113883.1.3 @extension st 1 … 1 F POCD_HD000040 hl7:templateId II 1 … 1 M Content module conformance PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.1.1 hl7:id II 1 … 1 M ID of the instance of this report PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.9   Here the OID for PAT exemplary instances, in practice the OID of the LIS @extension st 1 … 1 F 999-1   Here a hypothetical document ID   Constraint A report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report. The unique id of the current revision of the report is carried by the id element, and is composed of id@root, which SHALL be an OID,  and optionally id@extension, which can be any string so that the concatenation of the two attributes root and extension provide a globally unique id, which identifies this release of the report.  The version number of the current revision of the report is a positive integer (1, 2 …) provided in the versionNumber element. When the current revision of the report is not the first one, this new revision SHALL replace the previous one,  which SHALL be deprecated.  Hence the relatedDocument@typeCode attribute SHALL be valued “RPLC”,  and the relatedDocument/parentDocument/id SHALL provide the identifier of the previous revision that is to be deprecated.    Example Report ID <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="999-1" assigningAuthorityName="IHE PaLM Technical Committee"/> hl7:code CE CNE 1 … 1 M Document type PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @code CONF 1 … 1 F 11526-1 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) @displayName 1 … 1 F Pathology Study @codeSystemName 1 … 1 F LOINC hl7:title ST 1 … 1 M Report title PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF element content shall be "Anatomic Pathology Structured Report" hl7:effectiveTime TS 1 … 1 M Time of the report This is the date and time when the current version of the report was released. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:confidentialityCode CE 1 … 1 M Confidentiality level PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC) hl7:language​Code CS 1 … 1 M Principal language PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC) hl7:setId II 1 … 1 M Common identifier to all releases of this report PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.9 @extension st 1 … 1 F 999   Constraint A report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report. The unique id of the current revision of the report is carried by the id element, and is composed of id@root, which SHALL be an OID, and optionally id@extension, which can be any string so that the concatenation of the two attributes root and extension provide a globally unique id, which identifies this release of the report.  The setId element provides a globally unique identifier that is common across all successive revisions of the report. This identifier is similarly composed of setId@root, which SHALL be an OID, and optionally setId@extension.  The version number of the current revision of the report is a positive integer (1, 2 …) provided in the versionNumber element. When the current revision of the report is not the first one, this new revision SHALL replace the previous one, which SHALL be deprecated. Hence the relatedDocument@typeCode attribute SHALL be valued “RPLC”, and the relatedDocument/parentDocument/id SHALL provide the identifier of the previous revision that is to be deprecated.  Optionally the relatedDocument/parentDocument/versionNumber MAY provide the version number of the previous revision.   Associated with concepts: psr-data​element-50 Accession Number APSR 2.0 psr-data​element-32 Case APSR 2.0   Example Report set ID <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="999" assigningAuthorityName="IHE PaLM Technical Committee"/> hl7:versionNumber INT 0 … 1 Report version # PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @value int 1 … 1 F 1   Constraint A report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report. The unique id of the current revision of the report is carried by the id element, and is composed of id@root, which SHALL be an OID, and optionally id@extension, which can be any string so that the concatenation of the two attributes root and extension provide a globally unique id, which identifies this release of the report.  The setId element provides a globally unique identifier that is common across all successive revisions of the report. This identifier is similarly composed of setId@root, which SHALL be an OID, and optionally setId@extension.  The version number of the current revision of the report is a positive integer (1, 2 …) provided in the versionNumber element. When the current revision of the report is not the first one, this new revision SHALL replace the previous one, which SHALL be deprecated. Hence the relatedDocument@typeCode attribute SHALL be valued “RPLC”, and the relatedDocument/parentDocument/id SHALL provide the identifier of the previous revision that is to be deprecated.  Optionally the relatedDocument/parentDocument/versionNumber MAY provide the version number of the previous revision. hl7:informant 0 … * Zero or more informant may be mentioned in the header of the report. An informant is either an assignedEntity (a professional participating to the healthcare process, and who was assigned a defined role in that process) or a relatedEntity (a person who knows the patient and has provided relevant information concerning the patient). Hence the condition is either assignedEntity is present or relatedEntity is present. These two elements are defined in the content module “Informant”. Source: PaLM Suppl. APSR 2.0-3: 6.3.6.5 Contains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module Included 1 … 1 M from 2.16.840.1.113883.10.12.101 CDA recordTarget (DYNAMIC) Patient hl7:recordTarget 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode 0 … 1 F RCT @context​Control​Code 0 … 1 F OP   Associated with concepts: psr-data​element-2 Patient APSR 2.0 hl7:patientRole 1 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode 0 … 1 F PAT hl7:id II 1 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:addr AD 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   Associated with concepts: psr-data​element-18 Address APSR 2.0 psr-data​element-22 Country APSR 2.0 psr-data​element-21 City APSR 2.0 psr-data​element-20 ZIP Code APSR 2.0 psr-data​element-19 Street APSR 2.0 hl7:telecom TEL 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:patient 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:name PN 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   Associated with concepts: psr-data​element-5 Name APSR 2.0 psr-data​element-10 Surname APSR 2.0 psr-data​element-9 Family Name APSR 2.0 psr-data​element-14 Title APSR 2.0 hl7:administrative​Gender​Code CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 AdministrativeGender (DYNAMIC) hl7:birthTime TS 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:marital​Status​Code CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12212 MaritalStatus (DYNAMIC) hl7:religious​Affiliation​Code CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19185 ReligiousAffiliation (DYNAMIC) hl7:raceCode CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14914 Race (DYNAMIC) hl7:ethnic​Group​Code CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15836 Ethnicity (DYNAMIC) hl7:guardian 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode 1 … 1 F GUARD hl7:id II 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:code CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @codeSystem CONF 1 … 1 F 2.16.840.1.113883.5.111 (Role Code) hl7:addr AD 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:telecom TEL 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module Choice 1 … 1 Elements to choose from: hl7:guardian​Person containing template 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC) hl7:guardian​Organization containing template 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) hl7:guardian​Person Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:guardian​Organization Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:birthplace 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode 0 … 1 F BIRTHPL hl7:place 1 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode 0 … 1 F PLC @determiner​Code 0 … 1 F INSTANCE hl7:name EN 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:addr AD 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:language​Communication 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:language​Code CS 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC) hl7:modeCode CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12249 LanguageAbilityMode (DYNAMIC) hl7:proficiency​Level​Code CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.12199 LanguageAbilityProficiency (DYNAMIC) hl7:preference​Ind BL 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:providerOrganization 0 … 1 Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module Included 1 … * M from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author (DYNAMIC) The Author Content Module represents an author of the report. This element is repeatable. The sub-element author/time carries the date/time of the authoring action. Source: PAT TF-3: 6.2.6.2 hl7:author 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @typeCode cs 0 … 1 F AUT @context​Control​Code cs 0 … 1 F OP   Associated with concepts: psr-data​element-4 Pathologist APSR 2.0 psr-data​element-79 Device APSR 2.0   Example author is a person <author typeCode="AUT" contextControlCode="OP">   <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">     <!-- ... -->   </assignedAuthor></author> hl7:functionCode CE 0 … 1 PaLM 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) hl7:time TS.​DATE.​MIN 1 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assignedAuthor 1 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F ASSIGNED hl7:id II 1 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Choice 1 … 1 Elements to choose from: hl7:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person  … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Included 0 … * from 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC) @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device  … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name SC 1 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:softwareName SC 1 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:represented​Organization 1 … 1 M PaLM 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) @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 1 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Included 0 … * from 2.16.840.1.113883.10.12.103 CDA dataEnterer (DYNAMIC) Transcriptionist hl7:dataEnterer 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode 0 … 1 F ENT @context​Control​Code 0 … 1 F OP hl7:time TS 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:assignedEntity 1 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   Associated with concepts: psr-data​element-76 Secretary APSR 2.0 Included 1 … 1 M from 2.16.840.1.113883.10.12.104 CDA custodian (DYNAMIC) Custodian organization hl7:custodian 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode 0 … 1 F CST   Associated with concepts: psr-data​element-38 Custodian APSR 2.0 hl7:assignedCustodian 1 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode 0 … 1 F ASSIGNED hl7:represented​Custodian​Organization 1 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 1 … * M PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:name ON 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:telecom TEL 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:addr AD 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module Included 0 … * from 1.3.6.1.4.1.19376.1.3.3.1.4 Information Recipient (2008‑08‑08) The Intended Recipient Content Module represents a healthcare provider,  other than the ordering physician, expecting to receive a copy of the report. This repeatable element informationRecipient of the CDA header is used to list the intended recipients who were known at the time the report was created and issued. Source: PaLM TF-3: 6.3.2.14 hl7:information​Recipient 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 R   CONF The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19366 x_InformationRecipient (DYNAMIC) hl7:templateId II 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @root 1 … 1 F 1.3.6.1.4.1.19376.1.3.3.1.4 hl7:intended​Recipient 1 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode cs 1 … 1 R   CONF The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.16772 x_InformationRecipientRole (DYNAMIC) hl7:id II 0 … * R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:addr AD 1 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:telecom TEL 1 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:information​Recipient 0 … 1 Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:received​Organization 0 … 1 Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module Included 1 … 1 M from 2.16.840.1.113883.2.6.60.6.10.49 CDA legalAuthenticator IHE (DYNAMIC) Legal authenticator It describes a pathologist having verified the content of the report, using the element legalAuthenticator.  The report SHALL have one legal Authenticator Source: PaLM TF-3: 6.3.2.15 hl7:legalAuthenticator 1 … 1 M PaLM TF‑3: 6.3.2.15 Legal authenticator @typeCode cs 0 … 1 F LA @context​Control​Code cs 0 … 1 F OP   Associated with concepts: psr-data​element-4 Pathologist APSR 2.0 hl7:time TS 1 … 1 R PaLM TF‑3: 6.3.2.15 Legal authenticator hl7:signatureCode CS 1 … 1 R PaLM TF‑3: 6.3.2.15 Legal authenticator   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC) hl7:assignedEntity 1 … 1 R Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) PaLM TF‑3: 6.3.2.15 Legal authenticator Included 0 … * from 1.3.6.1.4.1.19376.1.8.1.4.3 CDA authenticator IHE (DYNAMIC) Content validator It describes a pathologist having verified the content of the report, using the element authenticator. This element authenticator is used when the pathologist having verified the content of the report is distinct from the pathologist assuming the legal responsibility for this report, described in the legalAuthenticator element. The report MAY have zero or more Content Validators. Source: PaLM Suppl. APSR 2.0-3: 6.3.6.3 hl7:authenticator 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator @typeCode cs 0 … 1 F AUTHEN   Constraint This content module does not contain any other content module. The report MAY have zero or more Content Validators.   Associated with concepts: psr-data​element-4 Pathologist APSR 2.0 hl7:time TS 1 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator hl7:signatureCode CS 1 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC) hl7:assignedEntity 1 … 1 R Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator Included 0 … 1 R from 1.3.6.1.4.1.19376.1.3.3.1.6 Ordering Provider (2008‑08‑08) Ordering physician The Ordering Provider Content Module represents the physician who has submitted the specimen examination order to the anatomic pathology laboratory. As specified in PaLM TF-3, this physician is represented in the CDA header as a participant element with the typeCode attribute valued “REF”. The sub-element participant/time carries the date/time of issuance of the order. Source: PaLM TF-3: 6.3.2.17 hl7:participant 0 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode 1 … 1 F REF hl7:templateId II 1 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @root 1 … 1 F 1.3.6.1.4.1.19376.1.3.3.1.6 hl7:time IVL_TS 0 … 1 R This element represents the date and time the order was placed. Time MAY be present. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:associated​Entity 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode 1 … 1 F PROV hl7:id II 1 … 1 R Unique identifier of this person (referral ordering physician) in the affinity domain SHALL be present. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:addr AD 1 … 1 R The address of this person (referral ordering physician) SHALL be present. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:telecom TEL.AT 1 … * R The telecom of this person (referral ordering physician) SHALL be present. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   Schematron assert role  error     test hl7:assigned​Person/hl7:name     Message An <assignedPerson> SHALL be present, the <name> sub-element SHALL be present.   hl7:associated​Person 1 … 1 R Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:scoping​Organization 0 … 1 Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module Included 0 … * R from 1.3.6.1.4.1.19376.1.8.1.4.1 CDA Participant Specimen Collector (DYNAMIC) Specimen collector Source: PAT TF-3: 6.2.6.1 hl7:participant 0 … * R The Specimen Collector Content Module is only used in case a specimen provided as input to the AP act documented in this report, was collected by a different party than the ordering physician. In that case, this specimen collector is represented in the CDA header as a participant element with the typeCode attribute valued “DIST” and the sub-element participant/time carries the time period of the specimen collection. PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector @typeCode cs 1 … 1 F DIST @context​Control​Code cs 0 … 1 F OP   Associated with concepts: psr-data​element-52 Specimen Collector APSR 2.0 psr-data​element-78 Clinician APSR 2.0 hl7:templateID II 1 … 1 R PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.4.1 hl7:time IVL_TS 1 … 1 R Specimen collection time The specimen collection time is an interval, which may be reduced to a point in time (see usage of data type IVL_TS). PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector hl7:associated​Entity 1 … 1 R At least one of the two elements associatedPerson and scopingOrganization must be present. Both may be present.  PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector @classCode cs 1 … 1 F PROV hl7:id II 1 … 1 R PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector hl7:code CE 0 … 1 PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector @codeSystem CONF 1 … 1 F 2.16.840.1.113883.5.111 (Role Code) hl7:addr AD 1 … 1 R PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector hl7:telecom TEL.AT 1 … * R PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector hl7:associated​Person 1 … 1 R Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC) PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector hl7:scoping​Organization 0 … 1 R Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector Included 0 … 1 R from 2.16.840.1.113883.10.12.109 CDA inFulfillmentOf (DYNAMIC) The inFulfillmentOf/order element MAY be present. It represents the Placer Order or the Placer Group that was fulfilled, the Id of which is carried by inFulfillmentOf/order/id. hl7:inFulfillmentOf 0 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode 0 … 1 F FLFS   Associated with concepts: psr-data​element-33 Order APSR 2.0 hl7:order 1 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode 0 … 1 F ACT @moodCode 1 … 1 F RQO hl7:id II 1 … * R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   Associated with concepts: psr-data​element-81 Order placer ID APSR 2.0 psr-data​element-82 Placer group ID APSR 2.0 psr-data​element-49 Order ID APSR 2.0 hl7:code CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @codeSystem CONF 1 … 1 F 2.16.840.1.113883.5.4 (Act Code) hl7:priorityCode CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC) Included 0 … 1 R from 1.3.6.1.4.1.19376.1.3.1.9999.10.9.15 DocumentationOf Laboratory Performer (DYNAMIC) Documented act. The service documented and the primary laboratory having performed it. Performing lab. The AP report is documenting a service (documentationOf/serviceEvent) performed by a pathology laboratory. The Laboratory Performer Content Module represents this laboratory, and is fully described in the sub-element documentationOf/serviceEvent/performer. In case more than one laboratory contributed to a service, only the primary laboratory is in the CDA header, attached to the serviceEvent element, and the other (secondary) laboratories are described only in the sections of the report that they contributed to, in the body of the report. Source: PaLM TF3: 6.3.2.19 hl7:documentationOf 0 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:serviceEvent 1 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   Associated with concepts: psr-data​element-50 Accession Number APSR 2.0 hl7:effectiveTime IVL_TS 0 … 1 Use of sub element documentationOf/serviceEvent/effectiveTime to document the time boundaries of events in the document is appropriate. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module lab:statusCode CS 0 … 1 This Laboratory Report Content Module can express both final and non-final reports. To distinguish between the two, the statusCode element has been added to the documentationOf/serviceEvent element. A non-final report is a report documenting a serviceEvent, which is in the status "active". This sub-element serviceEvent/statusCode is optional. When it is not present the serviceEvent is assumed to be in the status "completed". PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.4 ActStatusActiveCompleted (DYNAMIC) hl7:performer 0 … * Laboratory Performer template in the CDA header Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   Associated with concepts: psr-data​element-88 Pathology laboratory APSR 2.0 Included 0 … 1 R from 1.3.6.1.4.1.19376.1.3.1.9999.10.9.16 RelatedDocument Parent Document (DYNAMIC) This element SHALL be present in case of an update replacement of a previous report. In this case relatedDocument@typeCode attribute SHALL be valued "RPLC", the new report replacing the parent one.  hl7:relatedDocument 0 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 F RPLC   relatedDocument@typeCode attribute SHALL be valued "RPLC". hl7:parentDocument 1 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:id II 1 … 1 R SHALL be equal to ClinicalDocument/ id of the replaced document. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:setId II 1 … 1 R SHALL have the same value in the new report as in the replaced report. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:versionNumber INT 0 … 1 SHALL have the same value as in the replaced report (when provided there) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module Included 0 … 1 R from 2.16.840.1.113883.10.12.113 CDA componentOf (DYNAMIC) Patient encompassing encounter hl7:componentOf 0 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode 0 … 1 F COMP hl7:encompassing​Encounter 1 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode 0 … 1 F ENC @moodCode 0 … 1 F EVN hl7:id II 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:code CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC) hl7:effectiveTime IVL_TS 1 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:discharge​Disposition​Code CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF shall be drawn from concept domain "EncounterDischargeDisposition" hl7:responsible​Party 0 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode 0 … 1 F RESP hl7:encounterParticipant 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 R   CONF The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC) hl7:time IVL_TS 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:assignedEntity 1 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:location 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode 0 … 1 F LOC hl7:health​Care​Facility 1 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode 0 … 1 F SDLOC hl7:id II 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:code CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC) hl7:location 0 … 1 Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:service​Provider​Organization 0 … 1 Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:component 1 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:structuredBody 1 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode cs 1 … 1 F DOCBODY @moodCode cs 1 … 1 F EVN hl7:component 0 … 1 R The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, clinical laboratory data, specimen(s) description, collection procedure, reason for anatomic pathology procedure  Contains 1.3.6.1.4.1.19376.1.8.1.2.1 Clinical Information Section (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R The 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). Contains 1.3.6.1.4.1.19376.1.8.1.2.2 Intraoperative Observation Section (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R The Macroscopic Observation section contains the description of the specimen received or obtained by the laboratory (specimen type and state), the gross observation, links to gross images, if taken, processing information and tissue disposition (representative sampling and tissue submitted for additional studies or sent to biorepository. Contains 1.3.6.1.4.1.19376.1.8.1.2.3 Macroscopic Observation Section (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R The Microscopic Observation section contains optionally the histopathologic findings of the case and many laboratories use this section to record the results of histochemical and immunohistochemical stains. Contains 1.3.6.1.4.1.19376.1.8.1.2.4 Microscopic Observation Section (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R The Additional Specific Observation section includes additional pathologic finding(s) and the results of ancillary study(ies) with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken.  Contains 1.3.6.1.4.1.19376.1.3.10.3.1 Additional Specified Observation Section (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 1 … 1 M 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. Contains 1.3.6.1.4.1.19376.1.8.1.2.5 Diagnostic Conclusion Section (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module where [not(@nullFlavor)] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R The Procedure steps section contains the description of tissue dissection: representative specimens and derived specimens dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, electron microscopy, etc.) or biorepository. Contains 1.3.6.1.4.1.19376.1.8.1.2.6 Procedure Steps Section (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true