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Aktuelle Version vom 23. Januar 2018, 03:26 Uhr

Id1.3.6.1.4.1.19376.1.3.10.4.4Effective Date valid from 2016‑10‑06 13:12:00

There are versions of templates with this id:
  • AssessmentScalesObservationScoringSystemsAPSR as of 2016‑10‑06 13:12:00
  • AssessmentScalesScoringSystemsAPSR as of 2016‑10‑06 12:36:29
  • CDASupplyContainerAPSR2 as of 2016‑07‑29
StatusKyellow.png DraftVersion Label2.0
NameAssessmentScalesObservationScoringSystemsAPSRDisplay NameAssessment Scales Observation for Scoring Systems APSR2
Description
Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF)

Assessment scale observation for Scoring Systems, e.g. Nottingham- (Elston-Ellis-) Grading for invasive breast cancers, describing the summarized scale value
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.4
LabelPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
ClassificationCDA Entry Level Template
Open/ClosedClosed (only defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 7 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.3.10.4.3ContainmentKyellow.png ICD-O-3 Typing and Grading Observation (2.0)2015‑11‑29 17:03:18
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
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.3.10.9.42ContainmentKyellow.png Assessment Scoring System APSR 2.0 (2.0)2016‑10‑10 11:33:36
2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA Reference2005‑09‑07
RelationshipSpecialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 (2014‑05‑14 17:09:54)
Example
example for use case #1, ER-Allred Score
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.4.4"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="273249006" codeSystem="2.16.840.1.113883.6.96" displayName="Assessment scales"/>  <derivationExpr text="sum"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20170711113628"/>  </effectiveTime>  <priorityCode code="R" displayName="routine" codeSystem="2.16.840.1.113883.5.7"/>  <repeatNumber/>  <value xsi:type="PQ" value="8"/>  <interpretationCode code="RR" displayName="Reactive" codeSystem="2.16.840.1.113883.5.83"/>  <methodCode code="0114" codeSystem="2.16.840.1.113883.1.11.14079" displayName="Microscopy, Light"/>  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->
  </performer>  <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>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 0..* R -->
  <entryRelationship typeCode="SPRT">
    <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.42 'Assessment Scoring System APSR 2.0' (2016-10-10T11:33:36) -->
  </entryRelationship>  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
  </reference>  <referenceRange typeCode="REFV">
    <observationRange classCode="OBS" moodCode="EVN.CRT">
      <code code="--code--" codeSystem="2.16.840.1.113883.5.4"/>      <text/>      <value xsi:type="ANY"/>      <interpretationCode code="CAR" displayName="Carrier" codeSystem="2.16.840.1.113883.5.83"/>    </observationRange>  </referenceRange></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treetree.png@classCode
cs0 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.4.4
Treetree.pnghl7:id
II0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treetree.pnghl7:code
CE (extensible)1 … 1MAssessment scale, e.g. grading by scoringPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
 CONF
@code shall be "273249006"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SCT"
@displayName shall be "Assessment scales"
or
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.19918 ActCoverageAssessmentObservationValue (2014‑03‑26)
 Example
for use case #1
<code code="273249006" codeSystem="2.16.840.1.113883.6.96" displayName="Assessment scales (assessment scale)"/>
Treetree.pnghl7:derivationExpr
ST0 … 1RThis optional field can be used to specify how the total score is calculated. In most cases the total score will be the sum of its components. But complex mathematical functions and/or logical operations are possible as well.
PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treetree.pnghl7:text
ED0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
 Example
for use case #1
<text>Nottingham combined grad I (1 of 3)</text>
Treetree.pnghl7:statusCode
CS1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
 ConstraintThe 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.


 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (2014‑03‑26)
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treetree.pnghl7:value
ANY1 … *Rany total value of a scoring systems, e.g. Gleason score, van Nuys score, etc., either with data type INT or with data type CD or CO 
PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
 Example
for use case #1, Nottingham combined grade I
<value value="1"/>
Treetree.pnghl7:interpretationCode
CE0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)
Treetree.pnghl7:methodCode
CE0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.pngTreetree.png@code
CONF0 … 1F0114
Treeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.1.11.14079
Treeblank.pngTreetree.png@codeSystemName
0 … 1FHL7
Treeblank.pngTreetree.png@displayName
0 … 1FMicroscopy, Light
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 Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
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 Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
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 Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
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 Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.7']]
Included0 … *R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
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:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.10.9.42 Assessment Scoring System APSR 2.0 (2016‑10‑10 11:33:36)PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.42']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treetree.pnghl7:reference
0 … *RContains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treetree.pnghl7:referenceRange
0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFV
Treeblank.pngTreetree.pnghl7:observationRange
1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FOBS
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs0 … 1FEVN.CRT
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CD0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.5.4 (Act Code)
Treeblank.pngTreeblank.pngTreetree.pnghl7:text
ED0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
ANY0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretationCode
CE0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)
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