2.16.840.1.113883.2.6.60.6.10.1

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Template PathologyStructuredReport

Beschreibung

This Document Content Module defines the base set of constraints that apply to all AP structured report, related to any kind of lesion or diagnostic problem. In other words, this is the generic template for any AP structured report. The body of this Document Content Module and of all its specialized children, share a common hierarchy of sections and entries depicted by figure 4.1.2.1-1 in Volume 1 IHE_PAT_Suppl_Rev2 0_TI_2015_05_20

Aktuelle Version

Id	2.16.840.1.113883.2.6.60.6.10.1	Gültigkeit	gültig ab 2014‑05‑13 11:57:57
Status	Entwurf	Versions-Label
Name	PathologyStructuredReport	Anzeigename	Pathology Structured Report
Beschreibung	This Document Content Module defines the base set of constraints that apply to all AP structured report, related to any kind of lesion or diagnostic problem. In other words, this is the generic template for any AP structured report. The body of this Document Content Module and of all its specialized children, share a common hierarchy of sections and entries depicted by figure 4.1.2.1-1 in Volume 1 IHE_PAT_Suppl_Rev2 0_TI_2015_05_20
Klassifikation	CDA Document Level Template
Offen/Geschlossen	Offen (auch andere als die definierten Elemente sind erlaubt)
Assoziiert mit	Assoziiert mit 1 Konzept Id Name Datensatz psr-data​element-58 strukturierter Pathologiebefund PSR
Benutzt von / Benutzt	Benutzt von 0 Templates, Benutzt 19 Templates Benutzt Template-Id als Name Version 1.2.276.0.76.10.2001 Inklusion Header​Record​Target DYNAMIC 1.2.276.0.76.10.2015 Inklusion HeaderInFulfillmentOf DYNAMIC 1.2.276.0.76.10.2013 Inklusion HeaderParticipantEinsenderNotifiableDisease DYNAMIC 1.2.276.0.76.10.2002 Inklusion HeaderAuthor DYNAMIC 1.2.276.0.76.10.2004 Inklusion HeaderCustodian DYNAMIC 1.2.276.0.76.10.2018 Inklusion CDAinformant DYNAMIC 1.2.276.0.76.10.2005 Inklusion Header​Information​Recipient DYNAMIC 1.2.276.0.76.10.2020 Inklusion HeaderLegalAuthenticator DYNAMIC 1.2.276.0.76.10.2019 Inklusion HeaderAuthenticator DYNAMIC 2.16.840.1.113883.10.12.110 Inklusion CDAdocumentationOf DYNAMIC 2.16.840.1.113883.10.12.111 Inklusion CDArelatedDocument DYNAMIC 2.16.840.1.113883.10.12.114 Inklusion CDAauthorization DYNAMIC 2.16.840.1.113883.10.12.113 Inklusion CDAcomponentOf DYNAMIC 2.16.840.1.113883.2.6.60.6.10.5 Containment ClinicalInformationSection DYNAMIC 2.16.840.1.113883.2.6.60.6.10.3 Containment ProcedureStepsSection 2014‑05‑13 19:33:12 2.16.840.1.113883.2.6.60.6.10.2 Containment IntraoperativeObservationSection DYNAMIC 2.16.840.1.113883.2.6.60.6.10.7 Containment MacroscopySection DYNAMIC 2.16.840.1.113883.2.6.60.6.10.6 Containment MicroscopySection DYNAMIC 2.16.840.1.113883.2.6.60.6.10.4 Containment DiagnosticConclusionSection DYNAMIC
Beziehung	Spezialisierung: Template 2.16.840.1.113883.10.12.1 (2005‑09‑07)
Beispiel	Beispiel <ClinicalDocument>   <templateId root="2.16.840.1.113883.10.12.1"/>   <templateId root="2.16.840.1.113883.2.6.60.6.10.1"/>   <id root="1.3.6.1.4.1.19376.1.8.9" extension="--example only--"/>   <code code="11526-1" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology Study"/>   <title>Pathology Structured Report</title>  <effectiveTime value="20150730135347"/>   <confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25"/>   <!-- include template 1.2.276.0.76.10.2001 'CDA recordTarget' (dynamic) 1..1 R -->   <!-- include template 1.2.276.0.76.10.2015 'Auftragsidentifikation' (dynamic) 0..1 R -->   <!-- include template 1.2.276.0.76.10.2013 'CDA participant Einsender' (dynamic) 1..1 R -->   <!-- include template 1.2.276.0.76.10.2002 'CDA author' (dynamic) 1..* R -->   <!-- include template 1.2.276.0.76.10.2004 'CDA custodian' (dynamic) 0..1 O -->   <!-- include template 1.2.276.0.76.10.2018 'CDA Informant' (dynamic) 0..* O -->   <!-- include template 1.2.276.0.76.10.2005 'CDA informationRecipient' (dynamic) 0..* O -->   <!-- include template 1.2.276.0.76.10.2020 'CDA legalAuthenticator' (dynamic) 0..1 O -->   <!-- include template 1.2.276.0.76.10.2019 'CDA authenticator' (dynamic) 0..* O -->   <!-- include template CDAdocumentationOf '?' (dynamic) 0..* O -->   <!-- include template CDArelatedDocument '?' (dynamic) 0..* O -->   <!-- include template CDAauthorization '?' (dynamic) 0..* O -->   <!-- include template CDAcomponentOf '?' (dynamic) 0..1 O -->   <component typeCode="COMP" contextConductionInd="true">     <structuredBody classCode="DOCBODY" moodCode="EVN">       <component typeCode="COMP" contextConductionInd="true">         <!-- template 2.16.840.1.113883.2.6.60.6.10.5 'Clinical Information Section' (dynamic) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 2.16.840.1.113883.2.6.60.6.10.3 'Procedure Steps Section' (2014-05-13T19:33:12) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 2.16.840.1.113883.2.6.60.6.10.2 'Intraoperative Observation Section' (dynamic) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 2.16.840.1.113883.2.6.60.6.10.7 'Macroscopic Observation Section' (dynamic) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 2.16.840.1.113883.2.6.60.6.10.6 'Microscopic Observation Section' (dynamic) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 2.16.840.1.113883.2.6.60.6.10.4 'Diagnostic Conclusion Section' (dynamic) -->       </component>    </structuredBody>  </component></ClinicalDocument>
Item DT Kard Konf Beschreibung Label hl7:ClinicalDocument 0 … * (PathologyStructuredReport) @classCode cs 0 … 1 F DOCCLIN @moodCode cs 0 … 1 F EVN   Ziel der Konzept Id(s): psr-data​element-58 strukturierter Pathologiebefund PSR hl7:typeId II 1 … 1 R (PathologyStructuredReport) @root uid 1 … 1 F 2.16.840.1.113883.1.3 @extension st 1 … 1 F POCD_HD000040 hl7:templateId II 1 … 1 R (PathologyStructuredReport) @root uid 1 … 1 F 2.16.840.1.113883.10.12.1 hl7:templateId II 1 … 1 M (PathologyStructuredReport) @root uid 1 … 1 F 2.16.840.1.113883.2.6.60.6.10.1 hl7:id II 1 … 1 R (PathologyStructuredReport)   Constraint <id root="1.3.6.1.4.1.19376.1.8.9" extension="999"/> hl7:code CE 1 … 1 R (PathologyStructuredReport) @code 1 … 1 F 11526-1 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) @displayName 1 … 1 F Pathology Study @codeSystemName 1 … 1 F LOINC hl7:title ST 0 … 1 (PathologyStructuredReport)   CONF Elementinhalt muss "Pathology Structured Report" sein hl7:effectiveTime TS 1 … 1 R (PathologyStructuredReport) hl7:confidentialityCode CE 1 … 1 R (PathologyStructuredReport)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.16926 x_BasicConfidentialityKind (DYNAMIC) Eingefügt 1 … 1 Required von 1.2.276.0.76.10.2001 CDA recordTarget (DYNAMIC) hl7:recordTarget 1 … 1 R (PathologyStructuredReport) @typeCode 0 … 1 F RCT @context​Control​Code 0 … 1 F OP   Beispiel <recordTarget typeCode="RCT" contextControlCode="OP">   <patientRole classCode="PAT">     <!-- ... -->   </patientRole></recordTarget> hl7:patientRole 1 … 1 (PathologyStructuredReport) @classCode 0 … 1 F PAT   Beispiel <patientRole classCode="PAT">   <id extension="186245" root="1.2.276.0.76.3.1.139.3.871"/>   <patient classCode="PSN" determinerCode="INSTANCE">     <!-- ... -->   </patient></patientRole> hl7:id II 1 … * (PathologyStructuredReport)   Beispiel <id extension="6245" root="2.16.840.1.113883.3.933"/> <id extension="1543627549" root="1.2.276.0.76.4.1"/> hl7:addr AD 0 … * Adresse des Patienten (PathologyStructuredReport)   Beispiel <addr use="HP">   <streetName>Dorfstraße</streetName>  <houseNumber>54</houseNumber>  <postalCode>51371</postalCode>  <city>Leverkusen</city></addr> hl7:telecom TEL 0 … * Kontaktdaten des Patienten (PathologyStructuredReport)   Beispiel <telecom use="H" value="tel:+49.30.140400"/> <telecom use="MC" value="tel:+49.221.1234567"/> <telecom value="mailto:herberthannes.mustermann@provider.de"/> hl7:patient 0 … 1 (PathologyStructuredReport) @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE   Beispiel <patient classCode="PSN" determinerCode="INSTANCE">   <name>     <!-- ... -->   </name>  <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>   <birthTime value="19541223"/> </patient> hl7:name PN 1 … 1 M (PathologyStructuredReport)   Beispiel <name>   <given>Johannes</given>  <family>Tremener</family></name> hl7:administrative​Gender​Code CE 1 … 1 R Geschlecht (administrativ) des Patienten (PathologyStructuredReport)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.1 Administrative Gender (HL7 V3) (DYNAMIC)   Beispiel <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/> hl7:birthTime TS.​DATE.​MIN 1 … 1 R Geburtsdatum des Patienten (PathologyStructuredReport)   Beispiel <birthTime value="19491224"/> hl7:marital​Status​Code CE 0 … 1 Familienstand des Patienten (PathologyStructuredReport)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.12212 Marital Status (DYNAMIC)   Beispiel <maritalStatusCode code="S" displayName="Never Married" codeSystem="2.16.840.1.113883.5.2"/> hl7:religious​Affiliation​Code CE 0 … 1 Religionszugehörigkeit des Patienten (PathologyStructuredReport)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.19185 Religious Affiliation (DYNAMIC)   Beispiel <religiousAffiliationCode code="1077" displayName="Protestant" codeSystem="2.16.840.1.113883.5.1076"/> hl7:raceCode NP darf nicht verwendet werden (PathologyStructuredReport) hl7:ethnic​Group​Code NP darf nicht verwendet werden (PathologyStructuredReport) hl7:guardian 0 … * Vormund/Sachwalter des Patienten (PathologyStructuredReport) hl7:addr AD 0 … 1 (PathologyStructuredReport) hl7:telecom TEL 0 … * (PathologyStructuredReport) Auswahl 1 … 1 Elemente in der Auswahl: hl7:guardian​Person hl7:guardian​Organization hl7:guardian​Person (PathologyStructuredReport) hl7:name PN 1 … 1 M (PathologyStructuredReport) hl7:guardian​Organization (PathologyStructuredReport) hl7:name ON 1 … 1 M (PathologyStructuredReport) hl7:birthplace 0 … 1 Geburtsort des Patienten (PathologyStructuredReport)   Beispiel <birthplace>   <place>     <addr>Hamburg</addr>  </place></birthplace> hl7:place 1 … 1 M (PathologyStructuredReport) hl7:addr AD 1 … 1 M (PathologyStructuredReport) hl7:language​Communication 0 … * (PathologyStructuredReport) hl7:language​Code CS 0 … 1 (PathologyStructuredReport)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.11526 Language (DYNAMIC) hl7:modeCode CE 0 … 1 (PathologyStructuredReport)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.12249 LanguageAbilityMode (DYNAMIC) hl7:proficiency​Level​Code CE 0 … 1 (PathologyStructuredReport)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.12199 LanguageAbilityProficiency (DYNAMIC) hl7:preference​Ind BL 0 … 1 (PathologyStructuredReport) Eingefügt 0 … 1 Required von 1.2.276.0.76.10.2015 Auftragsidentifikation (DYNAMIC) hl7:inFulfillmentOf 0 … 1 R hifnd @typeCode 1 … 1 F FLFS hl7:templateId II 1 … * M hifnd @root 1 … 1 F 1.2.276.0.76.10.2015 hl7:order 1 … 1 M Auftrag hifnd @classCode 1 … 1 F ACT @moodCode 1 … 1 F RQO   Ziel der Konzept Id(s): psr-data​element-49 PSR hl7:id II 1 … 1 M Auftragsnummer, Anforderungsnummer hifnd Eingefügt 1 … 1 Required von 1.2.276.0.76.10.2013 CDA participant Einsender (DYNAMIC) hl7:participant 1 … 1 R hpeinnd wo [@typeCode='REF'] @typeCode 1 … 1 F REF @context​Control​Code 1 … 1 F OP hl7:templateId II 1 … * M hpeinnd @root 1 … 1 F 1.2.276.0.76.10.2013 hl7:templateId II 1 … * M hpeinnd @root 1 … 1 F 1.3.6.1.4.1.19376.1.3.3.1.6 hl7:time TS.​DATE.​MIN 1 … 1 R Auftragsdatum Das Auftragsdatum ist das Datum / Zeit an dem der Auftrag von Auftraggeber abgesendet wird. Das Auftragsdatum wird als time-Element beim Auftraggeber ausgeführt und ist verpflichtend anzugeben. Bei einer manuellen Erfassung eines Auftrags im Labor kann dieses als nullFlavor=“NA“ ausgeführt werden. hpeinnd   Beispiel <time value="201403091624"/> hl7:associated​Entity 1 … 1 M hpeinnd @classCode 1 … 1 F PROV hl7:id II 1 … 1 R Identifier des Auftraggebers hpeinnd hl7:addr AD 1 … * M Adresse des Auftraggebers hpeinnd hl7:telecom TEL 0 … * R Kontaktdaten hpeinnd hl7:associated​Person 0 … 1 Name des Auftraggebers hpeinnd Eingefügt  von 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC) @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 1 … 1 hpeinnd hl7:scoping​Organization 0 … 1 Organisation des Auftraggebers hpeinnd Eingefügt  von 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC) @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * hpeinnd hl7:name ON 1 … 1 hpeinnd hl7:telecom TEL 0 … * hpeinnd hl7:addr AD 0 … 1 hpeinnd Eingefügt 1 … * Required von 1.2.276.0.76.10.2002 CDA author (DYNAMIC) hl7:author 1 … * R (PathologyStructuredReport) @typeCode 0 … 1 F AUT @context​Control​Code 0 … 1 F OP   Beispiel <author typeCode="AUT" contextControlCode="OP">   <time value="201306101654"/>   <assignedAuthor classCode="ASSIGNED">     <!-- ... -->   </assignedAuthor></author> hl7:functionCode CE 0 … 1 (PathologyStructuredReport)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC) hl7:time TS.​DATE.​MIN 1 … 1 gibt den Zeitpunkt an, an dem der Autor seinen Beitrag am Dokument beendet hat; dies kommt bei einem Autoren praktisch überein mit ClinicalDocument.effectiveTime (PathologyStructuredReport) hl7:assignedAuthor 1 … 1 (PathologyStructuredReport) @classCode 0 … 1 F ASSIGNED hl7:id II 1 … * (PathologyStructuredReport) hl7:code CE 0 … 1 Fachgebiet/Spezialität des Gesundheitsdienstleister, z. B. Ärztin/Arzt für Allgemeinmedizin, Approbierte Ärztin/Approbierter Arzt, Fachärztin/Facharzt für Anästhesiologie und Intensivmedizin (PathologyStructuredReport) hl7:telecom TEL 0 … * (PathologyStructuredReport) Auswahl 1 … 1 Elemente in der Auswahl: hl7:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person  … 1 (PathologyStructuredReport) Eingefügt 0 … * von 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC) @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * (PathologyStructuredReport) hl7:assigned​Authoring​Device  … 1 (PathologyStructuredReport) @classCode 0 … 1 F DEV @determiner​Code 0 … 1 F INSTANCE hl7:manufacturer​Model​Name SC 1 … 1 (PathologyStructuredReport) hl7:softwareName SC 1 … 1 (PathologyStructuredReport) hl7:represented​Organization 1 … 1 M (PathologyStructuredReport)   Beispiel <representedOrganization classCode="ORG" determinerCode="INSTANCE">   <name>     <!-- ... -->   </name></representedOrganization> Eingefügt  von 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC) @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * (PathologyStructuredReport) hl7:name ON 1 … 1 (PathologyStructuredReport) hl7:telecom TEL 0 … * (PathologyStructuredReport) hl7:addr AD 0 … 1 (PathologyStructuredReport) Eingefügt 0 … 1 von 1.2.276.0.76.10.2004 CDA custodian (DYNAMIC) hl7:custodian 0 … 1 (PathologyStructuredReport) @typeCode 0 … 1 F CST   Beispiel <custodian typeCode="CST">   <assignedCustodian classCode="ASSIGNED">     <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">       <!-- ... -->     </representedCustodianOrganization>  </assignedCustodian></custodian> hl7:assignedCustodian 1 … 1 M (PathologyStructuredReport) @classCode 0 … 1 F ASSIGNED hl7:represented​Custodian​Organization 1 … 1 M (PathologyStructuredReport) @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 1 … 1 (PathologyStructuredReport) hl7:name ON 1 … 1 M (PathologyStructuredReport) hl7:telecom TEL 0 … * (PathologyStructuredReport) hl7:addr AD 0 … 1 (PathologyStructuredReport) Eingefügt 0 … * von 1.2.276.0.76.10.2018 CDA Informant (DYNAMIC) hl7:informant 0 … * (PathologyStructuredReport) @typeCode 0 … 1 F INF @context​Control​Code 0 … 1 F OP Auswahl 1 … 1 Elemente in der Auswahl: hl7:assignedEntity hl7:relatedEntity hl7:assignedEntity 0 … 1 Gesundheitsdienstleister (PathologyStructuredReport) Eingefügt  von 1.2.276.0.76.10.90012 CDA Assigned Entity Elements (DYNAMIC) hl7:id II 1 … * R (PathologyStructuredReport) hl7:addr AD 0 … 1 R (PathologyStructuredReport) hl7:telecom TEL 0 … * R (PathologyStructuredReport) hl7:assigned​Person 1 … 1 (PathologyStructuredReport) Eingefügt  von 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC) @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 1 … 1 (PathologyStructuredReport) hl7:represented​Organization 0 … 1 (PathologyStructuredReport) Eingefügt  von 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC) @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * (PathologyStructuredReport) hl7:name ON 1 … 1 (PathologyStructuredReport) hl7:telecom TEL 0 … * (PathologyStructuredReport) hl7:addr AD 0 … 1 (PathologyStructuredReport) hl7:relatedEntity 0 … 1 Verwandte, Bekannte, Sozialhelfer, Betreuer/Erzieher (PathologyStructuredReport) Eingefügt  von 1.2.276.0.76.10.90020 CDA RelatedEntity (Body) (DYNAMIC) @classCode cs 1 … 1 R   CONF Der Wert von @classCode muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.19316 RoleClassMutualRelationship (DYNAMIC) hl7:code CE 0 … 1 (PathologyStructuredReport)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.19563 PersonalRelationshipRoleType (DYNAMIC) hl7:addr AD 0 … * (PathologyStructuredReport) hl7:telecom TEL 0 … * (PathologyStructuredReport) hl7:effectiveTime IVL_TS 0 … 1 (PathologyStructuredReport) hl7:relatedPerson 0 … 1 (PathologyStructuredReport) Eingefügt 0 … * von 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC) @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * (PathologyStructuredReport) Eingefügt 0 … * von 1.2.276.0.76.10.2005 CDA informationRecipient (DYNAMIC) hl7:information​Recipient 0 … * (PathologyStructuredReport) @typeCode cs 0 … 1   Typ des Empfängers: im @typeCode der Participation kann angegeben werden, ob es sich um einen primären Empfänger handelt (default) oder einen sekundären Empfänger („CC Kopie"). Der typeCode PRCP ist der default.   CONF @typeCode muss "PRCP" sein oder @typeCode muss "TRC" sein hl7:intended​Recipient 1 … 1 M (PathologyStructuredReport) hl7:id II 1 … * R (PathologyStructuredReport) Auswahl 1 … * Elemente in der Auswahl: hl7:information​Recipient hl7:received​Organization hl7:information​Recipient 0 … 1 (PathologyStructuredReport) Eingefügt  von 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC) @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 1 … 1 (PathologyStructuredReport) hl7:received​Organization 0 … 1 (PathologyStructuredReport) Eingefügt  von 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC) @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * (PathologyStructuredReport) hl7:name ON 1 … 1 (PathologyStructuredReport) hl7:telecom TEL 0 … * (PathologyStructuredReport) hl7:addr AD 0 … 1 (PathologyStructuredReport) Eingefügt 0 … 1 von 1.2.276.0.76.10.2020 CDA legalAuthenticator (DYNAMIC) hl7:legalAuthenticator 0 … 1 (PathologyStructuredReport) @typeCode 0 … 1 F LA @context​Control​Code 0 … 1 F OP hl7:time TS 1 … 1 R (PathologyStructuredReport) hl7:signatureCode CS 1 … 1 R (PathologyStructuredReport)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC) hl7:assignedEntity 1 … 1 R (PathologyStructuredReport) Eingefügt  von 1.2.276.0.76.10.90012 CDA Assigned Entity Elements (DYNAMIC) hl7:id II 1 … * R (PathologyStructuredReport) hl7:addr AD 0 … 1 R (PathologyStructuredReport) hl7:telecom TEL 0 … * R (PathologyStructuredReport) hl7:assigned​Person 1 … 1 (PathologyStructuredReport) Eingefügt  von 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC) @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 1 … 1 (PathologyStructuredReport) hl7:represented​Organization 0 … 1 (PathologyStructuredReport) Eingefügt  von 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC) @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * (PathologyStructuredReport) hl7:name ON 1 … 1 (PathologyStructuredReport) hl7:telecom TEL 0 … * (PathologyStructuredReport) hl7:addr AD 0 … 1 (PathologyStructuredReport) Eingefügt 0 … * von 1.2.276.0.76.10.2019 CDA authenticator (DYNAMIC) hl7:authenticator 0 … * (PathologyStructuredReport) @typeCode 0 … 1 F AUTHEN hl7:time TS 1 … 1 R (PathologyStructuredReport) hl7:signatureCode CS 1 … 1 R (PathologyStructuredReport)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC) hl7:assignedEntity 1 … 1 R (PathologyStructuredReport) Eingefügt  von 1.2.276.0.76.10.90012 CDA Assigned Entity Elements (DYNAMIC) hl7:id II 1 … * R (PathologyStructuredReport) hl7:addr AD 0 … 1 R (PathologyStructuredReport) hl7:telecom TEL 0 … * R (PathologyStructuredReport) hl7:assigned​Person 1 … 1 (PathologyStructuredReport) Eingefügt  von 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC) @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 1 … 1 (PathologyStructuredReport) hl7:represented​Organization 0 … 1 (PathologyStructuredReport) Eingefügt  von 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC) @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * (PathologyStructuredReport) hl7:name ON 1 … 1 (PathologyStructuredReport) hl7:telecom TEL 0 … * (PathologyStructuredReport) hl7:addr AD 0 … 1 (PathologyStructuredReport) Eingefügt 0 … * von 2.16.840.1.113883.10.12.110 CDA documentationOf (DYNAMIC) hl7:documentationOf 0 … * (PathologyStructuredReport) @typeCode 1 … 1 F DOC hl7:serviceEvent 1 … 1 (PathologyStructuredReport) @classCode 1 … 1 F ACT @moodCode 1 … 1 F EVN hl7:id II 0 … * (PathologyStructuredReport) hl7:code CE 0 … 1 (PathologyStructuredReport) @codeSystem 1 … 1 F 2.16.840.1.113883.5.4 (Act Code) hl7:effectiveTime IVL_TS 0 … 1 (PathologyStructuredReport) hl7:performer 0 … * (PathologyStructuredReport) @typeCode cs 1 … 1 R   CONF Der Wert von @typeCode muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.19601 x_ServiceEventPerformer (DYNAMIC) hl7:functionCode CE 0 … 1 (PathologyStructuredReport)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC) hl7:time IVL_TS 0 … 1 (PathologyStructuredReport) hl7:assignedEntity 1 … 1 Beinhaltet 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) (PathologyStructuredReport) Eingefügt 0 … * von 2.16.840.1.113883.10.12.111 CDA relatedDocument (DYNAMIC) hl7:relatedDocument 0 … * (PathologyStructuredReport) @typeCode cs 1 … 1 R   CONF Der Wert von @typeCode muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.11610 x_ActRelationshipDocument (DYNAMIC) hl7:parentDocument 1 … 1 (PathologyStructuredReport) @classCode 0 … 1 F DOCCLIN @moodCode 0 … 1 F EVN hl7:id II 1 … * R (PathologyStructuredReport) hl7:code CD 0 … 1 (PathologyStructuredReport) @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) hl7:text ED 0 … 1 (PathologyStructuredReport) hl7:setId II 0 … 1 (PathologyStructuredReport) hl7:versionNumber INT 0 … 1 (PathologyStructuredReport) Eingefügt 0 … * von 2.16.840.1.113883.10.12.114 CDA Authorization (DYNAMIC) hl7:authorization 0 … * (PathologyStructuredReport) @typeCode 0 … 1 F AUTH hl7:consent 1 … 1 (PathologyStructuredReport) @classCode 0 … 1 F CONS @moodCode 0 … 1 F EVN hl7:id II 0 … * (PathologyStructuredReport) hl7:code CE 0 … 1 (PathologyStructuredReport) @codeSystem 1 … 1 F 2.16.840.1.113883.5.4 (Act Code) hl7:statusCode CS 1 … 1 R (PathologyStructuredReport) @code 1 … 1 F completed Eingefügt 0 … 1 von 2.16.840.1.113883.10.12.113 CDA componentOf (DYNAMIC) hl7:componentOf 0 … 1 (PathologyStructuredReport) @typeCode 0 … 1 F COMP hl7:encompassing​Encounter 1 … 1 (PathologyStructuredReport) @classCode 0 … 1 F ENC @moodCode 0 … 1 F EVN hl7:id II 0 … * (PathologyStructuredReport) hl7:code CE 0 … 1 (PathologyStructuredReport)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC) hl7:effectiveTime IVL_TS 1 … 1 R (PathologyStructuredReport) hl7:discharge​Disposition​Code CE 0 … 1 (PathologyStructuredReport)   CONF muss aus der Konzeptdomäne "EncounterDischargeDisposition" gewählt werden hl7:responsible​Party 0 … 1 Beinhaltet 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) (PathologyStructuredReport) @typeCode 0 … 1 F RESP hl7:encounterParticipant 0 … * (PathologyStructuredReport) @typeCode cs 1 … 1 R   CONF Der Wert von @typeCode muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC) hl7:time IVL_TS 0 … 1 (PathologyStructuredReport) hl7:assignedEntity 1 … 1 Beinhaltet 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) (PathologyStructuredReport) hl7:location 0 … 1 (PathologyStructuredReport) @typeCode 0 … 1 F LOC hl7:health​Care​Facility 1 … 1 (PathologyStructuredReport) @classCode 0 … 1 F SDLOC hl7:id II 0 … * (PathologyStructuredReport) hl7:code CE 0 … 1 (PathologyStructuredReport)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC) hl7:location 0 … 1 Beinhaltet 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC) (PathologyStructuredReport) hl7:service​Provider​Organization 0 … 1 Beinhaltet 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) (PathologyStructuredReport) hl7:component (PathologyStructuredReport) @typeCode cs 0 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true hl7:structuredBody (PathologyStructuredReport) @classCode cs 0 … 1 F DOCBODY @moodCode cs 0 … 1 F EVN hl7:component 0 … 1 R Beinhaltet 2.16.840.1.113883.2.6.60.6.10.5 Clinical Information Section (DYNAMIC) (PathologyStructuredReport) @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 1 … 1 R Beinhaltet 2.16.840.1.113883.2.6.60.6.10.3 Procedure Steps Section (2014‑05‑13 19:33:12) (PathologyStructuredReport) @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R Beinhaltet 2.16.840.1.113883.2.6.60.6.10.2 Intraoperative Observation Section (DYNAMIC) (PathologyStructuredReport) @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R Beinhaltet 2.16.840.1.113883.2.6.60.6.10.7 Macroscopic Observation Section (DYNAMIC) (PathologyStructuredReport) @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R Beinhaltet 2.16.840.1.113883.2.6.60.6.10.6 Microscopic Observation Section (DYNAMIC) (PathologyStructuredReport) @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 1 … 1 R Beinhaltet 2.16.840.1.113883.2.6.60.6.10.4 Diagnostic Conclusion Section (DYNAMIC) (PathologyStructuredReport) @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true

Zusammenstellung aller Versionen dieses Templates

• 2014-05-13 11:57:57 (In Entwicklung)