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Version vom 1. April 2017, 03:13 Uhr

Id1.3.6.1.4.1.19376.1.8.1.1.1Effective Date valid from 2014‑05‑13 11:57:57
StatusKyellow.png DraftVersion Label2.0
NameAnatomicPathologyStructuredReportContentModuleDisplay NameAnatomic Pathology Structured Report Content Module
DescriptionThis 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. 


ContextPathname //
LabelPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
ClassificationCDA Document Level Template
Open/ClosedClosed (only defined elements are allowed)
Associated with
Associated with 4 concepts
IdNameData Set
psr-data​element-58Anatomic Pathology Structured ReportAPSR 2.0
psr-data​element-50Accession NumberAPSR 2.0
psr-data​element-32CaseAPSR 2.0
psr-data​element-27(administrative) GenderAPSR 2.0
Used by / Uses
Used by 0 templates, Uses 21 templates
Uses Template id as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)DYNAMIC
2.16.840.1.113883.10.12.101IncludeKgreen.png CDA recordTargetDYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA authorDYNAMIC
2.16.840.1.113883.10.12.103IncludeKgreen.png CDA dataEntererDYNAMIC
2.16.840.1.113883.10.12.104IncludeKgreen.png CDA custodianDYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.4IncludeKgreen.png Information Recipient (2008)DYNAMIC
2.16.840.1.113883.2.6.60.6.10.49IncludeKyellow.png CDA legalAuthenticator IHEDYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.3IncludeKyellow.png CDA authenticator IHEDYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.6IncludeKgreen.png Ordering Provider (2008)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.1IncludeKyellow.png CDA Participant Specimen CollectorDYNAMIC
2.16.840.1.113883.10.12.109IncludeKgreen.png CDA inFulfillmentOfDYNAMIC
1.3.6.1.4.1.19376.1.3.1.9999.10.9.15IncludeKyellow.png DocumentationOf Laboratory Performer (2016)DYNAMIC
1.3.6.1.4.1.19376.1.3.1.9999.10.9.16IncludeKyellow.png RelatedDocument Parent Document (2016)DYNAMIC
2.16.840.1.113883.10.12.113IncludeKgreen.png CDA componentOfDYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.1ContainmentKyellow.png Clinical Information Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.2ContainmentKyellow.png Intraoperative Observation Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.3ContainmentKyellow.png Macroscopic Observation Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.4ContainmentKyellow.png Microscopic Observation Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.3.10.3.1ContainmentKyellow.png Additional Specified Observation Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.5ContainmentKyellow.png Diagnostic Conclusion Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.6ContainmentKyellow.png Procedure Steps Section (2.0)DYNAMIC
RelationshipSpecialization: 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>
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treetree.png@classCode
cs0 … 1FDOCCLIN
Treetree.png@moodCode
cs0 … 1FEVN
 Target.pngAssociated with concepts:
psr-data​element-58Anatomic Pathology Structured ReportAPSR 2.0
psr-data​element-27(administrative) GenderAPSR 2.0
Treetree.pnghl7:typeId
II1 … 1MCDA conformancePaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.1.3
Treeblank.pngTreetree.png@extension
st1 … 1FPOCD_HD000040
Treetree.pnghl7:templateId
II1 … 1MContent module conformancePaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.1.1
Treetree.pnghl7:id
II1 … 1MID of the instance of this reportPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.9
 Here the OID for PAT exemplary instances, in practice the OID of the LIS
Treeblank.pngTreetree.png@extension
st1 … 1F999-1
 Here a hypothetical document ID
 ConstraintA 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"/>
Treetree.pnghl7:code
CE CNE1 … 1MDocument typePaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@code
CONF1 … 1F11526-1
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@displayName
1 … 1FPathology Study
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treetree.pnghl7:title
ST1 … 1MReport titlePaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 CONF
element content shall be "Anatomic Pathology Structured Report"
Treetree.pnghl7:effectiveTime
TS1 … 1MTime 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
Treetree.pnghl7:confidentialityCode
CE1 … 1MConfidentiality levelPaLM 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)
Treetree.pnghl7:language​Code
CS1 … 1MPrincipal languagePaLM 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)
Treetree.pnghl7:setId
II1 … 1MCommon identifier to all releases of this reportPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.9
Treeblank.pngTreetree.png@extension
st1 … 1F999
 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.

 Target.pngAssociated with concepts:
psr-data​element-50Accession NumberAPSR 2.0
psr-data​element-32CaseAPSR 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"/>
Treetree.pnghl7:versionNumber
INT0 … 1Report version #


PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@value
int1 … 1F1
 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.

Treetree.pnghl7: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
Included1 … 1M from 2.16.840.1.113883.10.12.101 CDA recordTarget (DYNAMIC)
Patient

The anatomic pathology report is related to one single patient. 
  • A patient SHALL be identified with at least one unique id. 
  • The patient address and telecom SHALL be provided (or null flavored). 
  • The patient identity SHALL provide at least the patient full name, sex and date/time of birth. 
The use of race code (ethnicity) is not permitted (NP) in Germany.
Treetree.pnghl7:recordTarget
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
0 … 1FRCT
Treeblank.pngTreetree.png@context​Control​Code
0 … 1FOP
 Target.pngAssociated with concepts:
psr-data​element-2PatientAPSR 2.0
Treeblank.pngTreetree.pnghl7:patientRole
1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPAT
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 Target.pngAssociated with concepts:
psr-data​element-18Address APSR 2.0
psr-data​element-22CountryAPSR 2.0
psr-data​element-21CityAPSR 2.0
psr-data​element-20ZIP CodeAPSR 2.0
psr-data​element-19StreetAPSR 2.0
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:patient
0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 Target.pngAssociated with concepts:
psr-data​element-5NameAPSR 2.0
psr-data​element-10SurnameAPSR 2.0
psr-data​element-9Family NameAPSR 2.0
psr-data​element-14TitleAPSR 2.0
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:administrative​Gender​Code
CE0 … 1PaLM 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:birthTime
TS0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:marital​Status​Code
CE0 … 1PaLM 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:religious​Affiliation​Code
CE0 … 1PaLM 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:raceCode
CE0 … 1PaLM 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:ethnic​Group​Code
CE0 … 1PaLM 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:guardian
0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
1 … 1FGUARD
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF1 … 1F2.16.840.1.113883.5.111 (Role Code)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Choice1 … 1Elements 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7: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
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7: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
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:birthplace
0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FBIRTHPL
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:place
1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPLC
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
EN0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:language​Communication
0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:language​Code
CS0 … 1PaLM 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:modeCode
CE0 … 1PaLM 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:proficiency​Level​Code
CE0 … 1PaLM 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:preference​Ind
BL0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:providerOrganization
0 … 1Contains 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
Included1 … *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
Treetree.pnghl7:author
1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.png@typeCode
cs0 … 1FAUT
Treeblank.pngTreetree.png@context​Control​Code
cs0 … 1FOP
 Target.pngAssociated with concepts:
psr-data​element-4PathologistAPSR 2.0
psr-data​element-79DeviceAPSR 2.0
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor></author>
Treeblank.pngTreetree.pnghl7:functionCode
CE0 … 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 (DYNAMIC)
Treeblank.pngTreetree.pnghl7:time
TS.​DATE.​MIN1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC)
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
 … 1PaLM 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
SC1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
1 … 1MPaLM 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM 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
Included0 … * from 2.16.840.1.113883.10.12.103 CDA dataEnterer (DYNAMIC)
Transcriptionist
Treetree.pnghl7:dataEnterer
0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
0 … 1FENT
Treeblank.pngTreetree.png@context​Control​Code
0 … 1FOP
Treeblank.pngTreetree.pnghl7:time
TS0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.pnghl7:assignedEntity
1 … 1Contains 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
 Target.pngAssociated with concepts:
psr-data​element-76SecretaryAPSR 2.0
Included1 … 1M from 2.16.840.1.113883.10.12.104 CDA custodian (DYNAMIC)
Custodian organization
Treetree.pnghl7:custodian
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
0 … 1FCST
 Target.pngAssociated with concepts:
psr-data​element-38CustodianAPSR 2.0
Treeblank.pngTreetree.pnghl7:assignedCustodian
1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Custodian​Organization
1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Included0 … * from 1.3.6.1.4.1.19376.1.3.3.1.4 Information Recipient (DYNAMIC)
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
Treetree.pnghl7:information​Recipient
0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19366 x_InformationRecipient (DYNAMIC)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@root
1 … 1F1.3.6.1.4.1.19376.1.3.3.1.4
Treeblank.pngTreetree.pnghl7:intended​Recipient
1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1R
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.16772 x_InformationRecipientRole (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:information​Recipient
0 … 1Contains 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
Treeblank.pngTreeblank.pngTreetree.pnghl7:received​Organization
0 … 1Contains 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
Included1 … 1M 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

Treetree.pnghl7:legalAuthenticator
1 … 1MPaLM TF‑3: 6.3.2.15 Legal authenticator
Treeblank.pngTreetree.png@typeCode
cs0 … 1FLA
Treeblank.pngTreetree.png@context​Control​Code
cs0 … 1FOP
 Target.pngAssociated with concepts:
psr-data​element-4PathologistAPSR 2.0
Treeblank.pngTreetree.pnghl7:time
TS1 … 1RPaLM TF‑3: 6.3.2.15 Legal authenticator
Treeblank.pngTreetree.pnghl7:signatureCode
CS1 … 1RPaLM 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)
Treeblank.pngTreetree.pnghl7:assignedEntity
1 … 1RContains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)PaLM TF‑3: 6.3.2.15 Legal authenticator
Included0 … * 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
Treetree.pnghl7:authenticator
0 … *PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator
Treeblank.pngTreetree.png@typeCode
cs0 … 1FAUTHEN
 Constraint

This content module does not contain any other content module.

The report MAY have zero or more Content Validators.


 Target.pngAssociated with concepts:
psr-data​element-4PathologistAPSR 2.0
Treeblank.pngTreetree.pnghl7:time
TS1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator
Treeblank.pngTreetree.pnghl7:signatureCode
CS1 … 1RPaLM 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)
Treeblank.pngTreetree.pnghl7:assignedEntity
1 … 1RContains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator
Included0 … 1R from 1.3.6.1.4.1.19376.1.3.3.1.6 Ordering Provider (DYNAMIC)

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
Treetree.pnghl7:participant
0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
1 … 1FREF
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@root
1 … 1F1.3.6.1.4.1.19376.1.3.3.1.6
Treeblank.pngTreetree.pnghl7:time
IVL_TS0 … 1RThis 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
Treeblank.pngTreetree.pnghl7:associated​Entity
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@classCode
1 … 1FPROV
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1RUnique 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
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … 1RThe 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
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL.AT1 … *RThe 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 assertroleKred.png error 
 testhl7:assigned​Person/hl7:name 
 MessageAn <assignedPerson> SHALL be present, the <name> sub-element SHALL be present. 
Treeblank.pngTreeblank.pngTreetree.pnghl7:associated​Person
1 … 1RContains 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
Treeblank.pngTreeblank.pngTreetree.pnghl7:scoping​Organization
0 … 1Contains 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
Included0 … *R from 1.3.6.1.4.1.19376.1.8.1.4.1 CDA Participant Specimen Collector (DYNAMIC)
Specimen collector.

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.

Source: PAT TF-3: 6.2.6.1


Treetree.pnghl7:participant
0 … *RThe 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
Treeblank.pngTreetree.png@typeCode
cs1 … 1FDIST
Treeblank.pngTreetree.png@context​Control​Code
cs0 … 1FOP
 Target.pngAssociated with concepts:
psr-data​element-52Specimen CollectorAPSR 2.0
psr-data​element-78ClinicianAPSR 2.0
Treeblank.pngTreetree.pnghl7:templateID
II1 … 1RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.1
Treeblank.pngTreetree.pnghl7:time
IVL_TS1 … 1RSpecimen 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
Treeblank.pngTreetree.pnghl7:associated​Entity
1 … 1RAt 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
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FPROV
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF1 … 1F2.16.840.1.113883.5.111 (Role Code)
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … 1RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL.AT1 … *RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreeblank.pngTreetree.pnghl7:associated​Person
1 … 1RContains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreeblank.pngTreetree.pnghl7:scoping​Organization
0 … 1RContains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Included0 … 1R 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.
Treetree.pnghl7:inFulfillmentOf
0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
0 … 1FFLFS
 Target.pngAssociated with concepts:
psr-data​element-33OrderAPSR 2.0
Treeblank.pngTreetree.pnghl7:order
1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FACT
Treeblank.pngTreeblank.pngTreetree.png@moodCode
1 … 1FRQO
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 Target.pngAssociated with concepts:
psr-data​element-81Order placer IDAPSR 2.0
psr-data​element-82Placer group IDAPSR 2.0
psr-data​element-49Order IDAPSR 2.0
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF1 … 1F2.16.840.1.113883.5.4 (Act Code)
Treeblank.pngTreeblank.pngTreetree.pnghl7:priorityCode
CE0 … 1PaLM 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)
Included0 … 1R 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.


The statusCode below documentationOf/serviceEvent is an extension to the CDA R2 standard, added by PaLM TF-3 to distinguish a preliminary report (statusCode@code="active") from a final report (statusCode@code="completed"). 

The statusCode sub element is  further described in section A.3 of PaLM TF-3. This sub-element is optional. When it is not there, the documented Act is assumed to be completed and the report is assumed to be a final report.


This extension to the standard is protected by a dedicated namespace associated in the ClinicalDocument element to the prefix lab:

<Clinical Document  xmlns:lab="urn:oid:1.3.6.1.4.1.19376.1.3.2" … >

Source: PaLM TF3: 6.3.2.19


Treetree.pnghl7:documentationOf
0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.pnghl7:serviceEvent
1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 Target.pngAssociated with concepts:
psr-data​element-50Accession NumberAPSR 2.0
Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 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
Treeblank.pngTreeblank.pngTreetree.pnglab:statusCode
CS0 … 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)
Treeblank.pngTreeblank.pngTreetree.pnghl7: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
 Target.pngAssociated with concepts:
psr-data​element-88Pathology laboratoryAPSR 2.0
Included0 … 1R 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. 

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.
Treetree.pnghl7:relatedDocument
0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
cs1 … 1FRPLC
 

relatedDocument@typeCode attribute SHALL be valued "RPLC".

Treeblank.pngTreetree.pnghl7:parentDocument
1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1R

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
Treeblank.pngTreeblank.pngTreetree.pnghl7:setId
II1 … 1R

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
Treeblank.pngTreeblank.pngTreetree.pnghl7:versionNumber
INT0 … 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
Included0 … 1R from 2.16.840.1.113883.10.12.113 CDA componentOf (DYNAMIC)
Patient encompassing encounter
Treetree.pnghl7:componentOf
0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
0 … 1FCOMP
Treeblank.pngTreetree.pnghl7:encompassing​Encounter
1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FENC
Treeblank.pngTreeblank.pngTreetree.png@moodCode
0 … 1FEVN
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM 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)
Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:discharge​Disposition​Code
CE0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 CONF
shall be drawn from concept domain "EncounterDischargeDisposition"
Treeblank.pngTreeblank.pngTreetree.pnghl7:responsible​Party
0 … 1Contains 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
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
0 … 1FRESP
Treeblank.pngTreeblank.pngTreetree.pnghl7:encounterParticipant
0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:time
IVL_TS0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assignedEntity
1 … 1Contains 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
Treeblank.pngTreeblank.pngTreetree.pnghl7:location
0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
0 … 1FLOC
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:health​Care​Facility
1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FSDLOC
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:location
0 … 1Contains 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
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:service​Provider​Organization
0 … 1Contains 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
Treetree.pnghl7:component
1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl1 … 1Ftrue
Treeblank.pngTreetree.pnghl7:structuredBody
1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FDOCBODY
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 … 1FEVN
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1RThe 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
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
bl1 … 1Ftrue
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1R

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
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
bl1 … 1Ftrue
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1RThe 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
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
bl1 … 1Ftrue
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1R

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
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
bl1 … 1Ftrue
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1R

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
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
bl1 … 1Ftrue
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
1 … 1M

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
Treeblank.pngTreeblank.pngTreeblank.png where [not(@nullFlavor)]
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
bl1 … 1Ftrue
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1R

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
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
bl1 … 1Ftrue
Abgerufen von „https://wiki.hl7.de/index.php?title=1.3.6.1.4.1.19376.1.8.1.1.1/static-2014-05-13T115757&oldid=34912“