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Version vom 1. April 2017, 03:13 Uhr

Id1.3.6.1.4.1.19376.1.3.10.9.25Effective Date valid from 2014‑12‑02 15:54:17
StatusKyellow.png DraftVersion Label2.0
NameTNMTObservationDisplay NameTNM T-Observation
DescriptionTemplate CDA Observation (prototype, directly derived from POCD_RM000040 MIF)
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.25
ClassificationCDA Entry Level Template
Open/ClosedClosed (only defined elements are allowed)
Associated with
Associated with 4 concepts
IdNameData Set
psr-data​element-6T-categoryAPSR 2.0
psr-data​element-59PostoperativeAPSR 2.0
psr-data​element-61MultiplicityAPSR 2.0
psr-data​element-60ClinicalAPSR 2.0
Used by / Uses
Used by 10 templates, Uses 1 template
Used by Template id as NameVersion
1.3.6.1.4.1.19376.1.3.10.4.2ContainmentKyellow.png TNM Stage Observation (2.0)2014‑05‑13 15:45:13
1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKvalidblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
1.3.6.1.4.1.19376.1.8.1.3.6Link.pngKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.3.10.3.1Link.pngKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
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
1.3.6.1.4.1.19376.1.8.1.2.1Link.pngKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2Link.pngKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3Link.pngKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4Link.pngKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5Link.pngKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
Uses Template id as NameVersion
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen IdentifiedDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.9.25"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="21899-0" codeSystem="2.16.840.1.113883.6.1"/>  <statusCode code="normal"/>  <effectiveTime>
    <low value="20170308180152"/>  </effectiveTime>  <value xsi:type="CD" code="261663004" displayName="Tumor stage Ta (tumor staging)" codeSystem="2.16.840.1.113883.6.96">
    <qualifier>
      <name code="tnmCFactor" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="84068000" displayName="C1 - TNM certainty factor" codeSystem="2.16.840.1.113883.6.96"/>    </qualifier>    <qualifier>
      <name code="tnmCp" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="p" displayName="p" codeSystem="1.2.276.0.76.11.9"/>    </qualifier>    <qualifier>
      <name code="tnmMultiplicity" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="m" displayName="(m)" codeSystem="2.16.840.1.113883.15.6"/>    </qualifier>    <qualifier>
      <name code="tnmMucosaSymbol" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="m1" displayName="m1" codeSystem="2.16.840.1.113883.15.6"/>    </qualifier>    <qualifier>
      <name code="tnmSubmucosaSymbol" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="sm1" displayName="sm1" codeSystem="2.16.840.1.113883.15.6"/>    </qualifier>  </value>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 1..* R -->
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … 1R(TNMTObservation)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1R(TNMTObservation)
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.9.25
Treetree.pnghl7:id
II0 … *(TNMTObservation)
Treetree.pnghl7:code
CD CNE1 … 1M(TNMTObservation)
 CONF
@code shall be "21899-0"
@codeSystem shall be "2.16.840.1.113883.6.1"
@codeSystemName shall be "LOINC"
or
@code shall be "78873005"
@codeSystem shall be "2.16.840.1.113883.6.96"
@displayName shall be "T category (observable entity)"
@codeSystemName shall be "Snomed CT"
Treetree.pnghl7:statusCode
CS1 … 1R(TNMTObservation)
 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 … 1(TNMTObservation)
Treetree.pnghl7:value
CD0 … 1R(TNMTObservation)
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.12 UICC T category (SCT) (DYNAMIC)
or
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.15 UICC T category (DYNAMIC)
 Target.pngAssociated with concepts:
psr-data​element-6T-categoryAPSR 2.0
Treeblank.pngTreetree.pnghl7:qualifier
CR CWE0 … 1R(TNMTObservation)
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV CNE1 … 1Mfactor of Certainty(TNMTObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.276.0.76.3.1.131.1.5.1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1FtnmCFactor
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD CWE0 … 1R(TNMTObservation)
 Constraintin PSR only C4 allowed
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.20 UICC C-Factor (SCT) (DYNAMIC)
Treeblank.pngTreetree.pnghl7:qualifier
CR CWE0 … 1(TNMTObservation)
 Target.pngAssociated with concepts:
psr-data​element-59PostoperativeAPSR 2.0
psr-data​element-60ClinicalAPSR 2.0
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV CNE1 … 1Mclinical or pathological (TNMTObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.276.0.76.3.1.131.1.5.1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1FtnmCp
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD CWE0 … 1R(TNMTObservation)
 Constraintin PSR only "p" allowed
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.22 UICC clinical/pathological (DYNAMIC)
Treeblank.pngTreetree.pnghl7:qualifier
CR CWE0 … 1R(TNMTObservation)
 Target.pngAssociated with concepts:
psr-data​element-61MultiplicityAPSR 2.0
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV CNE1 … 1Mcode for multiple tumors in one organ(TNMTObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.276.0.76.3.1.131.1.5.1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1FtnmMultiplicity
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CV CWE0 … 1R(TNMTObservation)
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.37 UICC Multiplicity (DYNAMIC)
Treeblank.pngTreetree.pnghl7:qualifier
CR CWE0 … 1R(TNMTObservation)
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV CNE1 … 1M(TNMTObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.276.0.76.3.1.131.1.5.1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1FtnmMucosaSymbol
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD CWE0 … 1R(TNMTObservation)
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.26 UICC Mucosa (DYNAMIC)
Treeblank.pngTreetree.pnghl7:qualifier
CR CWE0 … 1R(TNMTObservation)
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV CNE1 … 1M(TNMTObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.276.0.76.3.1.131.1.5.1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1FtnmSubmucosaSymbol
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD CWE0 … 1R(TNMTObservation)
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.27 UICC Submucosa (DYNAMIC)
Included1 … *R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC)
Treetree.pnghl7:specimen
1 … *RRequired 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
 Target.pngAssociated with concepts:
psr-data​element-17Specimen identificationAPSR 2.0
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
 Target.pngAssociated with concepts:
psr-data​element-68Tissue section IDAPSR 2.0
psr-data​element-98Specimen IDAPSR 2.0
psr-data​element-66Part IDAPSR 2.0
psr-data​element-67Block IDAPSR 2.0
psr-data​element-95Parent IDAPSR 2.0
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