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Aktuelle Version vom 23. Januar 2018, 03:26 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/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 7 templates, Uses 11 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 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
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
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
1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
1.3.6.1.4.1.19376.1.3.1.6ContainmentKgreen.png Laboratory Observation (2017)2008‑08‑08
2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA Reference2005‑09‑07
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 IHE' (2016-06-21T14:02:11) -->
  </author>
  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->
  </informant>
  <participant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (2016-07-12T18:44:06) -->
  </participant>
  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->
  </performer>
  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 0..* R -->
  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (2016-06-22T16:08:01) -->
  </component>
  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' (2005-09-07T00:00:00) -->
  </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 'IHE Comment Entry' (2013-12-20T00:00:00) -->
  </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' (2014-05-14T17:09:54) -->
  </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' (2008-08-08T00:00:00) -->
  </component>
  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
  </reference>
</organizer>
Example
example for use case #1, problem: invasive breast cancer
<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' (2014-05-14T17:09:54) -->
  </component>
  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
  </reference>
</organizer>
ItemDTCardConfDescriptionLabel
hl7:organizer
0 … *RProblem 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
cs1 … 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 … *RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treetree.pnghl7:code
CD (required)0 … 1RProblem

PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.png@code
CONF0 … 1F75326-9
Treeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
0 … 1FLOINC
Treeblank.pngTreetree.png@displayName
0 … 1FProblem
Treetree.pnghl7:component
0 … 1RCoding of the Problem reportedPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.pnghl7:observation
0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CD (extensible)1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF0 … 1F75326-9
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
0 … 1FLOINC
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
0 … 1FProblem
Treeblank.pngTreeblank.pngTreeblank.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 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.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
CV0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1F116677004
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F2.16.840.1.113883.6.96
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st1 … 1F Associated topography (attribute)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:value
CD (extensible)0 … *RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF0 … 1F<< 91723000
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.6.96 (SNOMED Clinical Terms)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
0 … 1FSNOMED-CT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
0 … 1Fall values from Anatomical structure
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CE (extensible)0 … 1RCode of the problem reportedPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
 CONF
@code shall be "any_code"
@codeSystem shall be "2.16.840.1.113883.6.3"
@codeSystemName shall be "any_code"
@displayName shall be "ICD-10"
or
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.7 Problem Type (2016‑07‑11 09:52:19)
Treetree.pnghl7:statusCode
CS (required)1 … 1MPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
 ConstraintThe 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 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 … 1MOrganizer 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 (2016‑06‑21 14:02:11)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.png where [hl7:author [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.2']]]
 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 … *RInformant


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 (2016‑07‑08 11:22:58)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.6']]
Treetree.pnghl7:participant
0 … *RTranscriptionist, 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) (2016‑07‑12 18:44:06)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.7']]
 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 (2008‑08‑08)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
Included0 … *R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
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 … *REmbedded image


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



Contains 1.3.6.1.4.1.19376.1.8.1.4.10 Embedded Image IHE (2016‑06‑22 16:08:01)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.png where [hl7:observationMedia [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.10']]]
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 … *RRegion of interest


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

   

In the latter case by an entryRelationship @typeCode="SUBJ"

   




Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (2005‑09‑07)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.png where [@typeCode='COMP'] [hl7:regionOfInterest [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.307']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 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 … *RGeneral 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 (2013‑12‑20)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.png where [@typeCode='COMP'] [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
cs1 … 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 observations, e.g. for TNM, ICD-O-3, or Assessment scales, the appropriate templates may 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 (2014‑05‑14 17:09:54)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
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
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 (2008‑08‑08)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.png where [@typeCode='COMP'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.1.6']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 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:reference
0 … *RReference to an external document, or to external organizers, 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 Suppl. 2.0‑3: 6.3.5.2 Problem organizer