1.3.6.1.4.1.19376.1.8.1.3.6/static-2015-08-13T102455: Unterschied zwischen den Versionen

Aus Hl7wiki
Wechseln zu: Navigation, Suche
(Automated ADBot page content)
(Automated ADBot page content)
Zeile 1: Zeile 1:
<
+
<

Version vom 23. Mai 2017, 02:19 Uhr

Id1.3.6.1.4.1.19376.1.8.1.3.6Effective Date valid from 2015‑08‑13 10:24:55
StatusKyellow.png DraftVersion Label2.0
NameProblemOrganizerDisplay NameProblem Organizer
Description
Template CDA Organizer (prototype, directly derived from POCD_RM000040 MIF)

The problem organizer groups the battery of observations performed to investigate on a single problem identified on a specimen or group of specimens. 


ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.3.6
LabelPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
ClassificationCDA Entry Level Template
Open/ClosedClosed (only defined elements are allowed)
Used by / Uses
Used by 0 transactions and 7 templates, Uses 9 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.3.10.3.1ContainmentKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.1ContainmentKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2ContainmentKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3ContainmentKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4ContainmentKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5ContainmentKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA author IHEDYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.7ContainmentKyellow.png Additional participant in an entry APSR (Body)DYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2008)DYNAMIC
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen IdentifiedDYNAMIC
2.16.840.1.113883.10.12.307ContainmentKgreen.png CDA RegionOfInterestDYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.2ContainmentKgreen.png IHE Comment Entry (2014)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.3.1.6ContainmentKgreen.png Laboratory Observation (2008)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.305 (2005‑09‑07)
Example
generated example
<organizer classCode="BATTERY" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.3.6"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">
    <qualifier>
      <name code="116677004" codeSystem="2.16.840.1.113883.6.96" displayName=" Associated topography (attribute)"/>      <value nullFlavor="cs" code="all children of "362981000"" codeSystem="2.16.840.1.113883.6.96" displayName="all values from 91723000 (Anatomical structure)"/>    </qualifier>
  </code>
  <component typeCode="COMP">
    <observation>
      <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">
        <value code="115597007" displayName="Description of specimen character (procedure)" codeSystem="2.16.840.1.113883.6.96"/>      </code>
    </observation>
  </component>
  <statusCode code="completed"/>  <effectiveTime>
    <low value="20170131165954"/>  </effectiveTime>
  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) -->
  </author>
  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (dynamic) -->
  </informant>
  <participant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (dynamic) -->
  </participant>
  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'CDA Performer IHE (Body)' (dynamic) -->
  </performer>
  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 0..* R -->
  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' (dynamic) -->
  </component>
  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.4.2 'Annotation Comment (IHE)' (dynamic) -->
  </component>
  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (dynamic) -->
  </component>
  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.3.1.6 'Laboratory Observation' (dynamic) -->
  </component>
</organizer>
Example
example for use case #1, 1st problem
<organizer classCode="BATTERY" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.3.6"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_Problem1"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="201001041605-0500"/>  </effectiveTime>
  <!--The problem is expressed by the result of the observation having the same code as organizer/code-->
  <component>
    <observation classCode="OBS" moodCode="EVN">
      <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>      <value code="C50.9" codeSystem="2.16.840.1.113883.6.3" displayName="Malignant neoplasm of breast, unspecified" codeSystemDisplayName="ICD-10"/>    </observation>
  </component>
  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (dynamic) -->
  </component>
</organizer>
ItemDTCardConfDescriptionLabel
hl7:organizer
Problem organizer groups the battery of observations performed to investigate on a single problem identified on a specimen or a group of specimens. PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treetree.png@classCode
cs1 … 1FBATTERY
Treetree.png@moodCode
cs0 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.3.6
Treetree.pnghl7:id
II0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treetree.pnghl7:code
CD CNE0 … 1RProblem

The problem type code is unconstrained at this stage.
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.png@code
CONF1 … 1F75326-9
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@displayName
1 … 1FProblem
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.pnghl7:qualifier
CR0 … *ROptional qualifier for separate problems with identical problem type in one specimen, e.g. a urothelial bladder cancer Invasive cancer) and a prostate cancer (invasive cancer) in one cystoprostatectomy specimen. The anatomic structure is able to differentiate.
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
 Example
Problem in urinary bladder in a cystoprostatectomy specimen
<qualifier>
  <name code="116677004" codeSystem="2.16.840.1.113883.6.96" displayName="Associated topography (attribute)" codeSystemName="SNOMED-CT"/>  <value code="302512001" codeSystem="2.16.840.1.113883.6.96" displayName=" Entire urinary bladder (body structure)" codeSystemName="SNOMED-CT"/></qualifier>
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV0 … *RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
cs0 … 1F Associated topography (attribute)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs0 … 1F116677004
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid0 … 1F2.16.840.1.113883.6.96
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD CWE0 … *PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF1 … 1Fall children of "362981000"
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.96 (SNOMED Clinical Terms)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
1 … 1Fall values from 91723000 (Anatomical structure)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
1 … 1FSNOMED-CT
Treetree.pnghl7:component
0 … 1RCoding of the Problem reportedPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCOMP
Treeblank.pngTreetree.pnghl7:observation
CD0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CD CNE1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF1 … 1F75326-9
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
1 … 1FProblem
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:value
CE0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.7 Problem Type (DYNAMIC)
 Example
for use case #1, 1st problem (invasive cancer)
<value xsi:type="CD" code="C50.9" codeSystem="2.16.840.1.113883.6.3" displayName="Malignant neoplasm of mammary gland" codeSystemName="ICD-10"/>
Treetree.pnghl7:statusCode
CS CNE1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
 Constraint"completed" or "aborted"
The status of the organizer is completed if the battery of observations for this problem has been performed. It is aborted in case some of the intended observations could not be achieve and have been aborted, and appear as such below the organizer.

 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1ROrganizer time.
The period of time (possibly reduced to a point in time) during which the information was collected and assembled. 
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treetree.pnghl7:author
0 … *CAuthor

Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2

Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (DYNAMIC)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
 ConstraintThe author SHALL be present if it is different from the main author of the report. For instance the author could be the ordering physician contributing to the Clinical Information section, inside a report authored by the pathologist.
Treetree.pnghl7:informant
0 … *Informant

The informant is an actor (person and organization) who provided some of the clinical information carried by this organizer.


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. 2.0‑3: 6.3.5.2 Problem organizer
Treetree.pnghl7:participant
0 … *Transcriptionist, Device, Responsible, Validator


Source: PaLM Suppl. APSR 2.0-3: 6.3.6.6

Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry APSR (Body) (DYNAMIC)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
 ConstraintparticipationType "ENT", "DEV", "RESP", "AUTHEN"
Treetree.pnghl7:performer
0 … 1CPerforming lab.
The performing laboratory is present at this level only if this particular problem on this particular specimen was investigated by a (subcontractor) distinct laboratory from the one issuing the consolidated report

Source: 
PaLM TF-3: 6.3.2.20

Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Included0 … *R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC)
Specimen identification outside an AP observation for differentiating or restituting the problem type

Source: PaLM Suppl. APSR 2.0-3: 6.3.6.9
Treetree.pnghl7:specimen
0 … *RRequired in XD-LAB when more than one specimen is documented at this level. Always required in APSR.
PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreetree.png@typeCode
cs0 … 1FSPC
Treeblank.pngTreetree.pnghl7:specimenRole
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FSPEC
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treetree.pnghl7:component
0 … *Region of interest

This organizer may carry an image focusing on the problem, either directly embedded or encapsulated within a region of interest.



Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (DYNAMIC)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
 Constraint[@classCode="ROIOVL" and moodCode="EVN"]
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.pnghl7:seperatableInd
BL0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treetree.pnghl7:component
0 … *General comment on this particular problem 

Source: PCC TF-2: 6.3.4.6
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (DYNAMIC)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.pnghl7:seperatableInd
BL0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treetree.pnghl7:component
0 … *RAny kind of AP observation, for complex observation templates, e.g. for TNM, ICD-O-3, or Assessment scales can be used.

Source: PaLM Suppl. APSR 2.0-3: 6.3.6.7

Contains 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (DYNAMIC)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.pnghl7:seperatableInd
BL0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treetree.pnghl7:component
0 … *CLaboratory observation
Contains 1.3.6.1.4.1.19376.1.3.1.6 Laboratory Observation (DYNAMIC)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.pnghl7:seperatableInd
BL0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer