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	Anatomic Pathology Structured Report Content Module This Content Integration Profile describes a surgical pathology report as an electronic document to be published towards a document sharing resource such as an Electronic Health Record (EHR) or Personal Health Record (PHR) shared by a community of care providers, using one of the document sharing profiles defined in ITI-TF. Such an electronic document contains the set of releasable results produced by an surgical pathology laboratory in fulfillment of an Order or an Order Group for a patient. The report is shared in a human-readable format. In addition, this electronic anatomic pathology report SHALL contain diagnostic conclusions in a machine-readable format, to facilitate the integration of these observations in the database of a consumer system. 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-50 Accession Number APSR 2.0 psr-data​element-32 Case APSR 2.0 psr-data​element-58 Anatomic Pathology Structured Report APSR 2.0 psr-data​element-82 Placer group ID APSR 2.0
Used by / Uses	Used by 0 templates, Uses 22 templates Uses Template id as Name Version 1.3.6.1.4.1.19376.1.3.3.1.7 Containment Laboratory Performer (2008) DYNAMIC 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) DYNAMIC 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) DYNAMIC 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	example for use case #1 <hl7:ClinicalDocument xsi:schemaLocation="urn:hl7-org:v3 infrastructure/cda/CDA.xsd">   <hl7:realmCode code="UV"/>  <hl7:typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>  <hl7:templateId root="1.3.6.1.4.1.19376.1.8.1.1.1"/>  <hl7:id extension="A7102400008_1" root="1.3.6.1.4.1.19376.1.8.9.1"/>  <hl7:code code="11526-1" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology Study"/>  <hl7:title>Anatomic Pathology Structured Report - Breast Biopsy</hl7:title>  <hl7:effectiveTime value="20161202090407"/>  <hl7:confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25"/>  <hl7:languageCode code="en-US"/>  <hl7:setId extension="A7102400008" root="1.3.6.1.4.1.19376.1.8.9.1"/>  <hl7:versionNumber value="1"/>  <hl7:informant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Body) APSR2' (dynamic), not used in use case #1 -->   </hl7:informant>  <!-- Patient -->   <hl7:recordTarget>     <hl7:patientRole>       <hl7:id extension="0411886319605719371016" root="1.3.6.1.4.1.19376.1.8.9.2"/>      <hl7:addr use="HP">         <hl7:streetAddressLine>39 East Street</hl7:streetAddressLine>        <hl7:postalCode>69499</hl7:postalCode>        <hl7:city>Appleton</hl7:city>        <hl7:state>WI</hl7:state>        <hl7:country>United States</hl7:country>      </hl7:addr>      <hl7:telecom nullFlavor="NASK"/>      <hl7:patient>         <hl7:name>           <hl7:prefix>Miss</hl7:prefix>          <hl7:given>EVE</hl7:given>          <hl7:family qualifier="BR">ONEWOMAN</hl7:family>        </hl7:name>        <hl7:administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>        <hl7:birthTime value="19710921"/>      </hl7:patient>    </hl7:patientRole>  </hl7:recordTarget>  <!-- one or more author(s) of the report, with authoring time -->   <hl7:author>     <hl7:templateId root="1.3.6.1.4.1.19376.1.8.1.4.2"/>    <hl7:time value="20100104131933-0500"/>    <hl7:assignedAuthor>       <hl7:id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>      <hl7:addr nullFlavor="MSK"/>      <hl7:telecom value="tel:+33-602030499"/>      <hl7:assignedPerson>         <hl7:name>           <hl7:given>Marcel</hl7:given>          <hl7:family>Pathologist</hl7:family>          <hl7:suffix>Ph D</hl7:suffix>        </hl7:name>      </hl7:assignedPerson>      <hl7:representedOrganization>         <hl7:id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>        <hl7:name>CANCER INSTITUTE</hl7:name>        <hl7:telecom nullFlavor="MSK"/>        <hl7:addr nullFlavor="MSK"/>      </hl7:representedOrganization>    </hl7:assignedAuthor>  </hl7:author>  <!-- one or more transcriptionists, with transcription time -->   <hl7:dataEnterer>     <hl7:time value="20100104131720-0500"/>    <hl7:assignedEntity>       <hl7:id root="1.3.6.1.4.1.19376.1.8.9.3" extension="A32"/>      <hl7:addr nullFlavor="MSK"/>      <hl7:telecom nullFlavor="MSK"/>      <hl7:assignedPerson>         <hl7:name>           <hl7:given>Adeline</hl7:given>          <hl7:family>Medsecret</hl7:family>        </hl7:name>      </hl7:assignedPerson>    </hl7:assignedEntity>  </hl7:dataEnterer>  <!-- The unique custodian of this document is the sending pathology lab that will administer it (further updates, deprecation) -->   <hl7:custodian>     <hl7:assignedCustodian>       <hl7:representedCustodianOrganization>         <hl7:id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>        <hl7:name>CANCER INSTITUTE</hl7:name>        <hl7:telecom use="PUB" value="0466666666"/>        <hl7:addr>           <hl7:streetAddressLine>38 Cramberry Street</hl7:streetAddressLine>          <hl7:postalCode>69499</hl7:postalCode>          <hl7:city>Appleton</hl7:city>          <hl7:state>WI</hl7:state>        </hl7:addr>      </hl7:representedCustodianOrganization>    </hl7:assignedCustodian>  </hl7:custodian>  <!-- One or more additional intended recipients (other than the ordering physician) -->   <hl7:informationRecipient>     <hl7:templateId root="1.3.6.1.4.1.19376.1.3.3.1.4"/>    <hl7:intendedRecipient>       <hl7:id root="1.3.6.1.4.1.19376.1.8.9.3" extension="987"/>      <hl7:addr>         <hl7:streetAddressLine>1600 Clifton Road</hl7:streetAddressLine>        <hl7:city>Atlanta</hl7:city>        <hl7:state>GA</hl7:state>        <hl7:postalCode>30333</hl7:postalCode>      </hl7:addr>      <hl7:telecom value="tel:404-639-3535"/>      <hl7:informationRecipient>         <hl7:name>           <hl7:family>WOULDLIKETOKNOW</hl7:family>          <hl7:given>Thomas</hl7:given>        </hl7:name>      </hl7:informationRecipient>    </hl7:intendedRecipient>  </hl7:informationRecipient>  <!-- The unique legal authenticator: The person assuming the final responsibility of the report and signing it -->   <hl7:legalAuthenticator>     <hl7:time value="20100104152503-0500"/>    <hl7:signatureCode code="S"/>    <hl7:assignedEntity>       <hl7:id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>      <hl7:assignedPerson>         <hl7:name>           <hl7:given>Marcel</hl7:given>          <hl7:family>Pathologist</hl7:family>        </hl7:name>      </hl7:assignedPerson>    </hl7:assignedEntity>  </hl7:legalAuthenticator>  <!-- Zero or more additional content validator(s): pathologists having validated some part of the report -->   <hl7:authenticator>     <hl7:templateId root="1.3.6.1.4.1.19376.1.8.1.4.3"/>    <hl7:time value="20100104142503-0500"/>    <hl7:signatureCode code="S"/>    <hl7:assignedEntity>       <hl7:id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567898"/>      <hl7:addr nullFlavor="MSK"/>      <hl7:telecom nullFlavor="MSK"/>      <hl7:assignedPerson>         <hl7:name>           <hl7:given>Jonas</hl7:given>          <hl7:family>Jones</hl7:family>          <hl7:prefix>MD</hl7:prefix>        </hl7:name>      </hl7:assignedPerson>    </hl7:assignedEntity>  </hl7:authenticator>  <!-- The ordering physician -->   <hl7:participant typeCode="REF">     <hl7:templateId root="1.3.6.1.4.1.19376.1.3.3.1.6"/>    <hl7:time>       <hl7:high value="20091231"/>    </hl7:time>    <hl7:associatedEntity classCode="PROV">       <hl7:id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567892"/>      <hl7:addr nullFlavor="NASK"/>      <hl7:telecom value="tel:0147150000" use="EC"/>      <hl7:associatedPerson>         <hl7:name>           <hl7:prefix>Doctor</hl7:prefix>          <hl7:given>Eva</hl7:given>          <hl7:family>Surgeon</hl7:family>          <hl7:suffix>Ph D</hl7:suffix>        </hl7:name>      </hl7:associatedPerson>    </hl7:associatedEntity>  </hl7:participant>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.1 'CDA participant specimen collector' (dynamic) 0..* R, not used in use case #1 -->   <!-- Identification of the order, extension is Order-ID -->   <inFulfillmentOf>     <order>       <id root="1.3.6.1.4.1.19376.1.8.9.8" extension="12345"/>    </order>  </inFulfillmentOf>  <!-- Documented act(s): The pathology examination procedure, extension is Accession number -->   <documentationOf>     <serviceEvent>       <id root="1.3.6.1.4.1.19376.1.8.9.9" extension="A7102400008"/>      <code code="PATREPE" displayName="pathology report entry task" codeSystem="2.16.840.1.113883.5.4" codeSystemName="HL7 ActCode/"/>      <effectiveTime>         <!-- Start: Date&time of reception of this order and the attached specimens -->         <low value="200912300922-0500"/>        <!-- End -->         <high value="201001041605-0500"/>      </effectiveTime>      <!-- Performing laboratory -->       <performer typeCode="PRF">         <templateId root="1.3.6.1.4.1.19376.1.3.3.1.7"/>        <time>           <high value="201001041605-0500"/>        </time>        <assignedEntity>           <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>          <representedOrganization>             <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>            <name>CANCER INSTITUTE</name>            <telecom nullFlavor="MSK"/>            <addr nullFlavor="MSK"/>          </representedOrganization>        </assignedEntity>      </performer>    </serviceEvent>  </documentationOf>  <!-- include template 1.3.6.1.4.1.19376.1.3.1.9999.10.9.16 'RelatedDocument Parent Document' (dynamic) 0..1 R, not used in use case #1 -->   <!-- Patient encounter: The patient stay in the hospital where the surgery was performed -->   <componentOf>     <encompassingEncounter>       <id root="1.3.6.1.4.1.19376.1.8.9.7" extension="234567890"/>      <code code="ACUTE" displayName="inpatient acute"/>      <effectiveTime>         <high value="2201001040735-0500"/>      </effectiveTime>      <location typeCode="LOC">         <healthCareFacility classCode="SDLOC">           <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="11223344"/>          <serviceProviderOrganization classCode="ORG" determinerCode="INSTANCE">             <name>Surgery theater</name>            <asOrganizationPartOf>               <wholeOrganization>                 <name>CANCER INSTITUTE</name>              </wholeOrganization>            </asOrganizationPartOf>          </serviceProviderOrganization>        </healthCareFacility>      </location>    </encompassingEncounter>  </componentOf>  <!-- Structured body -->   <hl7:component typeCode="COMP" contextConductionInd="true">     <hl7:structuredBody classCode="DOCBODY" moodCode="EVN">       <hl7:component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.1 'Clinical Information Section' (dynamic) -->       </hl7:component>      <hl7:component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.2 'Intraoperative Observation Section' (dynamic) -->       </hl7:component>      <hl7:component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.3 'Macroscopic Observation Section' (dynamic) -->       </hl7:component>      <hl7:component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.4 'Microscopic Observation Section' (dynamic) -->       </hl7:component>      <hl7:component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.3.10.3.1 'Additionally Specified Observation Section' (dynamic) -->       </hl7:component>      <hl7:component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.5 'Diagnostic Conclusion Section' (dynamic) -->       </hl7:component>      <hl7:component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.6 'Procedure Steps Section' (dynamic) -->       </hl7:component>    </hl7:structuredBody>  </hl7:component></hl7: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 hl7:realmCode CS CNE 1 … 1 M This element SHALL be present and is valued from the RealmOfUse [2.16.840.1.113883.1.11.11050] subset, within the VocabularyDomainQualifier value set. In the international context of this profile used as it is without any further extension, the realm code SHALL be <realmCode code="UV"/> (universal). Whenever a national extension has been defined and is used, the realm code SHALL identify this national extension. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:typeId II 1 … 1 M This element is a technology-neutral explicit reference to the standard CDA R2. It SHALL be present and valued as follows: ClinicalDocument/typeId@root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models); ClinicalDocument.typeId@extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description). 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 This element is identifying the set of constraints applied to the CDA R2 standard by this IHE specification of a laboratory report. The following templateId SHALL be present and valued as follows to indicate compliance with the APSR 2.0 content module specification. 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 ClinicalDocument/Id SHALL be present. It represents the unique instance identifier of the clinical document. The combination of the root and extension attributes SHALL provide a globally unique identifier, in accordance with CDA R2, without further constraints. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @root uid 1 … 1 R Here the OID for PAT exemplary instances, in practice the OID of the LIS @extension st 1 … 1 R Here a hypothetical document ID, most often derived from the accession number   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.    Example Report ID from use case #1 <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_1" assigningAuthorityName="IHE PaLM Technical Committee"/> hl7:code CE CNE 1 … 1 M ClinicalDocument/code SHALL be present. The document type of this content module is always <code code="11526-1" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology Study" codeSystemName="LOINC"/> 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 The APSR <title> SHALL be present. It is the local translation of the code@displayName. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF element content shall be "Anatomic Pathology Structured Report"   Example Report title from use case #1 <title>ANATOMIC PATHOLOGY REPORT - BREAST BIOPSY</title> hl7:effectiveTime TS 1 … 1 M ClinicalDocument/effectiveTime SHALL be present. It contains the creation date & time of the laboratory report as an electronic document. In case this is a new revision replacing a previous version (identified in parentDocument), this is the date & time of the new revision. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:confidentialityCode CE 1 … 1 M ClinicalDocument/confidentialityCode SHALL be present in accordance with the HL7 CDA R2 standard. 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 ClinicalDocument/languageCode SHALL be present in accordance with the HL7 CDA R2 standard. 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 ClinicalDocument/setId SHALL be present to enable further updates of the clinical document. It is an identifier that is common across all revisions of this laboratory report. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @root uid 1 … 1 R @extension st 1 … 1 R   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 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.    Associated with concepts: psr-data​element-50 Accession Number APSR 2.0 psr-data​element-32 Case APSR 2.0   Example Report set ID from use case #1 <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008" assigningAuthorityName="IHE PaLM Technical Committee"/> hl7:versionNumber INT 0 … 1 R ClinicalDocument/versionNumber MAY be present. As requested by the CDA standard, it is an integer value used as versioning. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @value int 1 … 1 R   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 version number of the current revision of the report is a positive integer (1, 2 …) provided in the versionNumber element.   Example Report version number for use case #1 <versionNumber value="1"/> hl7:inFulfillmentOf 0 … 1 R 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. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 F FLFS hl7:order 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode cs 1 … 1 F ACT @moodCode cs 1 … 1 F RQO hl7:id II 1 … * R Placer order group ID or Placer order ID PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   Associated with concepts: psr-data​element-82 Placer group ID APSR 2.0 hl7:documentationOf ANY 1 … 1 M Documented act. The service documented and the primary surgical pathology laboratory having performed it (Performing lab). The AP report is documenting a service (documentationOf/serviceEvent) performed by a surgical 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 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 F DOC hl7:serviceEvent 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode cs 1 … 1 R @moodCode cs 1 … 1 R hl7:id II 1 … * M ID of the Act, i.e. Accession number 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:code CE CWE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF @code shall be "PATREPE" @codeSystem shall be "2.16.840.1.113883.5.4" @displayName shall be "pathology report entry task" @codeSystemName shall be "HL7 ActCode" or @code shall be "371528001" @codeSystem shall be "2.16.840.1.113883.6.96" @displayName shall be "Pathology report (record artifact)" @codeSystemName shall be "SCT" hl7:effectiveTime IVL_TS 0 … 1 R 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 hl7:statusCode CS CNE 0 … 1 R 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 … * R 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 hl7:relatedDocument 0 … 1 R ClinicalDocument/relatedDocument/parentDocument 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. Note 1: A non-final laboratory report published in an XDS infrastructure will likely be replaced afterwards by the final report. When this event occurs, the Content Creator Actor SHALL apply the following rules: ClinicalDocument/setId SHALL have the same value in the new report as in the replaced report. ClinicalDocument/versionNumber SHALL be incremented in the replacing report (i.e., the final one). ClinicalDocument/relatedDocument@typeCode attribute SHALL be valued ”RPLC” ClinicalDocument/relatedDocument/parentDocument/id in the new report SHALL be equal to ClinicalDocument/ id of the replaced document. The Document Source Actor SHALL apply the following rules on XDSDocumentEntry metadata: The final report SHALL be associated with the previously published one, using RPLC relationship and the previous report SHALL be “Deprecated” as described in ITI TF-2:4.1.6.1. Note 2: A non-final report can also be replaced by a more recent, albeit still non-final report. The rules above also apply in this case. Note 3: A final report can also be replaced by a corrective final report. The rules above also apply in this case. 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 ANY 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:id II 1 … 1 M 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 M 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 R 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 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 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 and Austria 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)   Associated with concepts: psr-data​element-27 (administrative) Gender APSR 2.0 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 (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 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 (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 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. 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 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-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 1 … 1 M 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 hl7:documentationOf 1 … 1 M 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 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.  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: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