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[[Category:Template]]
 
[[Category:Template]]
 
=Template ''APObservationEntry''=
 
=Template ''APObservationEntry''=
 
==Description==
 
==Description==
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<p>Template CDA Observation (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF).
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        Template CDA Observation (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF).
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This Content Module is usable within a Problem Organizer.
 
This Content Module is usable within a Problem Organizer.
 
The “AP Observation” generic template is usable for all AP observations, including ancillary techniques.
 
The “AP Observation” generic template is usable for all AP observations, including ancillary techniques.
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An AP observation has a status and an effective time, may describe various participants (persons, devices, organizations), may have a number of additional properties (method, interpretation, text), and may contain embedded images, comments, and sub-observations, which are also AP observations.
 
An AP observation has a status and an effective time, may describe various participants (persons, devices, organizations), may have a number of additional properties (method, interpretation, text), and may contain embedded images, comments, and sub-observations, which are also AP observations.
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Aktuelle Version vom 22. Dezember 2017, 03:18 Uhr

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Template APObservationEntry

Description

Template CDA Observation (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF). This Content Module is usable within a Problem Organizer. The “AP Observation” generic template is usable for all AP observations, including ancillary techniques. Each specific AP observation is associated to a specific template, child of the “AP Observation” generic template. This specific child template has exactly the same structure as the generic one, and brings only a number of vocabulary constraints related to the type of observation and to the type of organ source of the specimen observed:  The code for the specific observation, defined as a value set bound to the observation/code element, containing a single triplet (code, codeSystem, displayName) representing this specific observation. The cardinalities and default type for the observation/value element carrying the results of this observation. The domain of values for this observation in case these values are coded. This domain of coded values is defined as a value set bound to the observation/value element, containing as many triplets (code, codeSystem, displayName) as there are admissible result values for this specific observation performed on a specimen taken from this specific organ. An AP observation has a status and an effective time, may describe various participants (persons, devices, organizations), may have a number of additional properties (method, interpretation, text), and may contain embedded images, comments, and sub-observations, which are also AP observations.

Actual version

Id1.3.6.1.4.1.19376.1.8.1.4.9Effective Date valid from 2014‑05‑14 17:09:54
StatusKyellow.png DraftVersion Label2.0
NameAPObservationEntryDisplay NameAP Observation Entry
Description
This content module is usable within a Problem organizer.
   
The “AP Observation” generic template is usable for all AP observations, including ancillary techniques. 

An AP observation has a status and an effective time, may describe various participants (persons, devices, organizations), may have a number of additional properties (method, interpretation, text), and may contain embedded images, comments, and sub-observations, which are also AP observations.

ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.4.9
LabelPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 9 templates, Uses 10 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.3.10.3.1Link.pngKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.1Link.pngKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2Link.pngKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3Link.pngKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4Link.pngKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5Link.pngKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)2016‑07‑08 11:22:58
1.3.6.1.4.1.19376.1.8.1.4.7ContainmentKyellow.png Additional participant in an entry APSR (Body)2016‑07‑12 18:44:06
1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
1.3.6.1.4.1.19376.1.8.1.4.10ContainmentKyellow.png Embedded Image IHE2016‑06‑22 16:08:01
2.16.840.1.113883.10.12.307ContainmentKgreen.png CDA RegionOfInterest2005‑09‑07
1.3.6.1.4.1.19376.1.5.3.1.4.2ContainmentKgreen.png IHE Comment Entry (2014)2013‑12‑20
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA Reference2005‑09‑07
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Example
Observation example for use case #1, estrogen receptor
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.4.9"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="16112-5" codeSystem="2.16.840.1.113883.6.1" displayName="Estrogen receptor [Interpretation] in Tissue"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20161129162112"/>  </effectiveTime>  <value xsi:type="CD" code="416053008" displayName="Estrogen receptor positive tumor (disorder)" codeSystem="2.16.840.1.113883.6.96"/>  <methodCode code="0107" displayName="Microscopy" codeSystem="2.16.840.1.113883.5.84"/>  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'CDA Performer IHE (Body)' (dynamic) -->
  </performer>  <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(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>  <entryRelationship xsi:type="" typeCode="COMP">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (dynamic) -->
  </entryRelationship>  <entryRelationship xsi:type="" typeCode="COMP">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (dynamic) -->
  </entryRelationship>  <entryRelationship xsi:type="" typeCode="COMP">
    <!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' (dynamic) -->
  </entryRelationship>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 0..* O -->
  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (dynamic) -->
  </reference></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … *RPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1MPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.9
Treetree.pnghl7:id
II0 … *RPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treetree.pnghl7:code
CE (extensible)1 … 1MThe Anatomic pathology observation code should be taken from a reference terminology, preferably the LOINC terminology. National terminologies may be used.PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.pngTreetree.png@code
CONF1 … 1Feach_code_for_observable_entities_or_a_specific_procedure
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1Fsee_above
 Example<code code="59847-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Histology and Behavior ICD-O-3"/>
Treetree.pnghl7:text
ED0 … 1RNarrative text about the observationPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treetree.pnghl7:statusCode
CS (required)1 … 1MThe observation statusCode is “completed” if the observation was actually performed and has produced a result in the 

value  

element. In other cases the status of the intended observation is “aborted” and the result will never come.		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 (DYNAMIC)
Alert.pngError: Cannot find value set "1.3.6.1.4.1.19376.1.3.11.2"
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1MDate and time the observation has been made
PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treetree.pnghl7:value
ANY0 … *RObservation values using the appropriate data type.


Numeric results use data type PQ, which includes the unit. The result is absent in case of ‘aborted’ observation.


PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
 ConstraintThe default data type, cardinalities and value set for the <value> element are dependant on the type of observation.
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.11 AP Observation (2015‑11‑22 12:20:34)
 Example
for observation on tumor type
<value code="8500/3" codeSystem="2.16.840.1.113883.6.43.1" codeSystemName="ICD-O-3" displayName="Invasive carcinoma of the breast, no special type"/>
Treetree.pnghl7:interpretationCode
CE (extensible)0 … 1R

One or more codes interpreting the result, expressed with ObservationInterpretation vocabulary (e.g., H = high, L = low). 

    This element may be coded with other values than those of the ObservationInterpretation vocabulary, given that the coding strength is CWE (coded with exceptions).

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)
Treetree.pnghl7:methodCode
CE (extensible)0 … 1RPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (2014‑03‑26)
Treetree.pnghl7:performer
II0 … 1CPerforming lab


Source: PaLM TF-3: 6.3.2.20



Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
 ConstraintThe performing laboratory is present at this level only if this particular observation was performed by a (subcontractor) laboratory distinct from the one issuing the rest of the observations in this organizer.
Treetree.pnghl7:author
II0 … *CAuthor


   Source: PaLM TF 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 (2016‑06‑21 14:02:11)		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.png where [hl7:author [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.2']]]
Treetree.pnghl7:informant
II0 … *RInformant


Source: PaLM TF 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 (2016‑07‑08 11:22:58)		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.6']]
Treetree.pnghl7:participant
II0 … *RAdditional participants


Source: PaLM TF 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) (2016‑07‑12 18:44:06)		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.7']]
Treetree.pnghl7:entryRelationship
0 … *RSub-Observation


The result obtained for an observation may lead to an additional AP observation to refine this result. This sub-observation is again an Anatomic Pathology Observation. 

   
       
Source: Source: PaLM TF 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 (2014‑05‑14 17:09:54)		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.png where [@typeCode='COMP'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.9']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7:entryRelationship
0 … *REmbedded image. 


This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest. 

Source: PaLM TF Suppl. APSR 2.0-3 : 6.3.6.8

Contains 1.3.6.1.4.1.19376.1.8.1.4.10 Embedded Image IHE (2016‑06‑22 16:08:01)		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.png where [@typeCode='COMP'] [hl7:observationMedia [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.10']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7:entryRelationship
0 … *RRegion of Interest

Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (2005‑09‑07)		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.png where [@typeCode='COMP'] [hl7:regionOfInterest [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.307']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
 ConstraintThis observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest.
In the latter case by an entryRelationship @typeCode="SUBJ"
Treetree.pnghl7:entryRelationship
0 … *RAnnotation comment

Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20)		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.png where [hl7:act [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.20.1.40'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.2']]]
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCOMP
Included1 … *M from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Specimen identification
 Example
Example for specimen referencing
<specimen>
  <!-- which specimen is used for this observation -->
  <specimenRole>
    <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="slide_A_1_PR"/>  </specimenRole></specimen>
Treetree.pnghl7:specimen
1 … *MRequired 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:reference
0 … *RReference to an external document, or to external observations, e.g. concerning molecular pathology or  genetic testing report
Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

List of all versions of this template

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