Item | DT | Card | Conf | Description | Label |
---|
| | 0 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section |
| @classCode
|
| cs | 0 … 1 | F | DOCSECT |
| @moodCode
|
| cs | 0 … 1 | F | EVN |
| Constraint | This section SHALL contain a code element populated with these attributes: @code="46059-2" @codeSystem="2.16.840.1.113883.6.1" @displayName="Special treatments and procedures section" This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader. This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document. The section SHOULD contain as many Specimen Procedure Steps entry elements as there are procedure steps or groups thereof to be described. These entries provide the machine-readable data corresponding to the narrative block. |
| | Associated with concepts:psr-dataelement-23 | Procedure | APSR 2.0 |
|
| hl7:templateId
|
| II | 1 … 1 | M | | PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section |
| | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.8.1.2.6 |
| hl7:code
|
| CE | 1 … 1 | M | | PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section |
| | @code
|
| CONF | 1 … 1 | F | 46059-2 |
| | @codeSystem
|
| 1 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) |
| | @displayName
|
| 1 … 1 | F | Special treatments and procedures section |
| | @codeSystemName
|
| 1 … 1 | F | LOINC |
| hl7:title
|
| ST | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section |
| CONF | element content shall be "PROCEDURE STEPS SECTION" |
|
| hl7:text
|
| SD.TEXT | 1 … 1 | M | | PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section |
| Example | <text>Part #1 is labeled “left breast biopsy” and has been sampled for frozen section preparation. Numerous sections are submitted for permanent processing. Part #2 received in two pieces is labeled "apical left axillary tissue". Both pieces are rendered into numerous sections and submitted in their entirety for history. </text> |
Included | 0 … * | C | from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author (DYNAMIC) Author
Source: PaLM Suppl.APSR 2.0‑3:6.3.6.2
|
| hl7:author
|
| | 0 … * | C | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | @typeCode
|
| cs | 0 … 1 | F | AUT |
| | @contextControlCode
|
| cs | 0 … 1 | F | OP |
| | Associated with concepts:psr-dataelement-4 | Pathologist | APSR 2.0 | psr-dataelement-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 |
| cs | 0 … 1 | F | ASSIGNED |
| II | 1 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| CE | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| TEL | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
Choice | 1 … 1 | | Elements to choose from:- hl7:assignedPerson
- hl7:assignedAuthoringDevice
|
| | … 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) |
| | 0 … 1 | F | PSN |
| | 0 … 1 | F | INSTANCE |
| PN | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | | | hl7:assignedAuthoringDevice
|
| | … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| cs | 0 … 1 | F | DEV |
| cs | 0 … 1 | F | INSTANCE |
| | | | | hl7:manufacturerModelName
|
| SC | 1 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| SC | 1 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | | hl7:representedOrganization
|
| | 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) |
| | 0 … 1 | F | ORG |
| | 0 … 1 | F | INSTANCE |
| II | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| ON | 1 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| TEL | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| AD | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| hl7:entry
|
| | 0 … * | R | Specimen procedure steps
Source: PaLM Suppl.APSR 2.0‑3:6.2.5.3 Contains 1.3.6.1.4.1.19376.1.3.10.4.1 Specimen Procedure Step (DYNAMIC) | PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | | |