| Item | DT | Card | Conf | Description | Label |
|---|
| | 0 … * | R | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
 | @classCode
|
| cs | 1 … 1 | F | PROC |
| @moodCode
|
| cs | 1 … 1 | F | EVN |
| hl7:templateId
|
| II | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
 | | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.3.10.4.1 |
| hl7:id
|
| II | 0 … * | R | Procedure ID, coming from the LIS.
May be the target (referenced) ID for the child procedure. | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| hl7:code
|
| CD (extensible) | 1 … 1 | M | Coded procedure | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| | Constraint | for specimen collection procedure codes for targetSite or SNOMED CT have to be used, for specimen processing (down step the procedures) SNOMED CT is preferred, DICOM could be used if available
|
| | CONF | | The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.10 Specimen Collection and Processing (2016‑05‑31 15:09:59) |
|
| | Example | for use case #1, specimen collection <code code="122548005" codeSystem="2.16.840.1.113883.6.96" displayName="Biopsy of breast (procedure)" codeSystemName="SNOMED-CT"/> |
| | Example | for use case #1, grossing & embedding <code code="40923002" codeSystem="2.16.840.1.113883.6.96" displayName="Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)"/> |
| | Example | for use case #1, sectioning & immunostaining <code code="117617002" codeSystem="2.16.840.1.113883.6.96" displayName="Immunohistochemistry procedure (procedure)"/> |
| | hl7:qualifier
|
| CR (extensible) | 0 … * | C | Qualifier for staining or other procedures which don´t have values in the vocabulary used.
| PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| | Constraint | Used only in staining and other procedures without values in SCT or LOINC or DICOM vocabulary, e.g. immune stains
|
| | Example | for use case #1, grossing & embedding <qualifier>
<name code="246355002" displayName="Supporting structure (attribute)" codeSystem="2.16.840.1.113883.6.96"/> <value code="702941008" displayName="Paraffin embedding (qualifier value)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/></qualifier> |
| | Example | for use case #1, Estrogen receptor staining <qualifier>
<name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/> <value code="23307004" displayName="Estrogen receptor (substance)" codeSystem="2.16.840.1.113883.6.96"/></qualifier> |
| | Example | for use case #1, ISH Her-2-neu staining <qualifier>
<name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/> <value code="164870" displayName="ONCOGENE ERBB2" codeSystem="2.16.840.1.113883.6.174" codeSystemName="OMIM"/></qualifier> |
| CV (extensible) | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| cs | 0 … 1 | F | 246094008_or_246355002 |
| oid | 0 … 1 | F | 2.16.840.1.113883.6.96 |
| st | 0 … 1 | F | Component investigated (attribute) or Supporting structure (attribute) |
| CD (extensible) | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| cs | 1 … 1 | R | |
| | CONF | | @code shall be "<<105590001 | Substance (substance) |" | | @codeSystem shall be "2.16.840.1.113883.6.96" | | @codeSystemName shall be "SNOMED-CT" | | @displayName shall be "values from substance axis, e.g. Estrogen receptor" | | or | | @code shall be "values from G axis" | | @codeSystem shall be "2.16.840.1.113883.6.174" | | @codeSystemName shall be "OMIM" | | @displayName shall be "values from G axis, e.g. erb-b2" | | or | | @code shall be "<<272394005 | Technique (qualifier value) |" | | @codeSystem shall be "2.16.840.1.113883.6.96" | | @codeSystemName shall be "SNOMED-CT" | | @displayName shall be "values from technique axis, e.g. Paraffin embedded (qualifier)" |
|
| hl7:text
|
| ED | 0 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| | Example | specimen collection procedure <text>ULTRASOUND GUIDED NEEDLE CORE BIOPSY</text> |
| | Example | specimen processing procedure <text>CUTTING A SLIDE FROM A PARAFFIN BLOCK</text> |
| hl7:statusCode
|
| CS (required) | 0 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC) |
|
| hl7:effectiveTime
|
| IVL_TS | 0 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| hl7:approachSiteCode
|
| CD (extensible) | 0 … 1 | R | Approach site in specimen collection | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| | @code
|
| CONF | 0 … 1 | F | any_code |
| | @codeSystem
|
| 0 … 1 | F | 2.16.840.1.113883.5.1052 (Act Site) |
| | @codeSystemName
|
| 0 … 1 | F | any_code |
| | @displayName
|
| 0 … 1 | F | ActSite |
| hl7:targetSiteCode
|
| CD (extensible) | 0 … 1 | R | Target site in body or relative parent relationship in case of specimen processing | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| | CONF | | @code shall be "<<123037004 | Body structure (body structure) |" | | @codeSystem shall be "2.16.840.1.113883.6.96" | | @codeSystemName shall be "SCT" | | @displayName shall be "all children of Body structure (body structure)" | | or | | @code shall be "any_code" | | @codeSystem shall be "2.16.840.1.113883.5.1052" | | @codeSystemName shall be "ActSite" | | @displayName shall be "any_code" | | or | | The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.9 Procedure Site (2016‑06‑01 18:46:15) |
|
| | Example | for use case #1, specimen collection <targetSiteCode code="110497008" displayName="Lower outer quadrant of right breast (body structure)" codeSystem="2.16.840.1.113883.6.96"/> |
| | Example | for use case #1, grossing & embedding <targetSiteCode code="309050000" displayName="Body substance sample" codeSystem="2.16.840.1.113883.6.96"/> |
| | hl7:qualifier
|
| CR (extensible) | 0 … * | C | optional qualifiers for specifying body structures or / and laterality | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| | Example | for use case #1, (optional) specification of body structure for specimen collection <qualifier>
<name code="118169006" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen source topography (attribute)" codeSystemName="SNOMED-CT"/> <value code="255495000" codeSystem="2.16.840.1.113883.6.96" displayName="Right lower quadrant (qualifier value)" codeSystemName="SNOMED-CT"/></qualifier> |
| CV (extensible) | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| st | 0 … 1 | F | Specimen source topography |
| oid | 1 … 1 | F | 2.16.840.1.113883.6.96 |
| cs | 1 … 1 | F | 118169006 |
| CD (extensible) | 0 … * | R | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| CONF | 0 … 1 | | @code shall be out of choice:- <<272099008
- Descriptor (qualifier value)
|
| 0 … 1 | F | 2.16.840.1.113883.6.96 (SNOMED Clinical Terms) |
| 0 … 1 | F | SCT |
| 0 … 1 | F | all children of "Descriptor, qualifier values", e.g. right lower quadrantt |
| hl7:methodCode
|
| CD (extensible) | 0 … * | R | Identifies the technique used to perform a procedure
| PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| | @codeSystem
|
| cs | 1 … 1 | F | 2.16.840.1.113883.5.1065 |
| Included | 0 … 1 | R | from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Parent specimen with parent ID |
| | Example | for use case #1, parent specimen ID in grossing & embedding <specimen typeCode="SPC">
<specimenRole classCode="SPEC">
<!-- Parent specimen ID -->
<id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008"/> </specimenRole></specimen> |
| hl7:specimen
|
| | 0 … 1 | R | Required 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 |
| | @typeCode
|
| cs | 0 … 1 | F | SPC |
| | hl7:specimenRole
|
| | 1 … 1 | M | | PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified |
| cs | 0 … 1 | F | SPEC |
| II | 1 … 1 | R | Specimen ID, coming from the LIS | PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified |
| hl7:performer
|
| | 0 … 1 | R | Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08) | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.3.1.7']] |
| |
| hl7:author
|
| | 0 … * | C | 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: 6.3.5.3 Specimen procedure steps |
| where [hl7:author [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.2']]] |
| |
| hl7:participant
|
| | 1 … * | M | One or more specimen (with additives), which participates as product of the procedure
Contains 1.3.6.1.4.1.19376.1.3.10.9.44 CDA Participant (Body) Procedure Steps APSR2 (2014‑10‑26 17:06:28) | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| where [not(@nullFlavor)] |
| |
| hl7:entryRelationship
|
| | 0 … * | R | Artificial material (manufactured product) which
containes
the specimen
Contains 1.3.6.1.4.1.19376.1.3.10.9.22 CDA Supply Container APSR2 (2016‑07‑29 12:09:33) | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| where [@typeCode='COMP'] [hl7:supply [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.9.22']]] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | Constraint | for manufactured product
classCode = MANU
for DrugOrOtherMaterial
classCode = MMAT
code from MaterialEntityClassType
|
| hl7:entryRelationship
|
| | 0 … 1 | R | Specimen arrival in Lab
Contains 1.3.6.1.4.1.19376.1.3.1.3 Specimen Received (2008‑08‑08) | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| where [@typeCode='COMP'] [hl7:act [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.1.3']]] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| hl7:entryRelationship
|
| | 0 … * | R | Referencing mechanism to the ID of the child procedures, giving a lis of child procedure IDs
Contains 1.3.6.1.4.1.19376.1.3.10.4.1 Specimen Procedure Step (2016‑07‑08 13:20:59) | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| where [@typeCode='REFR'] [hl7:procedure [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.4.1']]] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | REFR |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | Constraint | contains only ID of the child procedure, which is fully described in a dedicated entry further down in the Procedure step section. |
| hl7:reference
|
| | 0 … * | R | Reference to an external document, or to external procedures, 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: 6.3.5.3 Specimen procedure steps |
Draft
