1.3.6.1.4.1.19376.1.8.1.2.3/static-2014-05-13T115709: Unterschied zwischen den Versionen

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<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.3</td><th style="width: 20em; text-align: left;">Effective Date</th><td style="text-align: left;"> valid from 2014‑05‑13 11:57:09</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|16px]] Draft</td><th style="width: 20em; text-align: left;">Version Label</th><td style="text-align: left;">2.0</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">MacroscopySection</td><th style="width: 20em; text-align: left;">Display Name</th><td style="text-align: left;">Macroscopic Observation Section</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Description</th><td style="text-align: left;" colspan="3"><span lang="EN-US" style="mso-no-proof:no">The Macroscopic Observation section contains the description of the specimen(s) received or obtained by the laboratory (specimen type and state), the gross observation, links to gross images, if taken, processing information and tissue disposition (representative sampling and tissue submitted for additional studies or sent to biorepository.</span></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Context</th><td style="text-align: left;" colspan="3">Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.3</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Label</th><td style="text-align: left;" colspan="3">PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section<br /></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Classification</th><td style="text-align: left;" colspan="3">CDA Section Level Template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Open/Closed</th><td style="text-align: left;" colspan="3">Closed (only defined elements are allowed)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Associated with</th><td style="text-align: left;" colspan="3"><table class="treetable" id="assocsTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Associated with 2 concepts</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Id</th><th style="width: 60%; text-align: left;">Name</th><th style="width: 20%; text-align: left;">Data Set</th></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;"><span style="color: grey;">psr-data&#8203;element-</span>30</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Observation / ">Macroscopic observation</td><td style="text-align: left; vertical-align: top;">APSR 2.0</td></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;"><span style="color: grey;">psr-data&#8203;element-</span>31</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Observation / Macroscopic observation / ">macroscopic observation text</td><td style="text-align: left; vertical-align: top;">APSR 2.0</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Used by / Uses</th><td style="text-align: left;" colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Used by 1 template, Uses 2 templates</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Used by Template id</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.1.1</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Anatomic Pathology Structured Report Content Module (2.0)</td><td style="text-align: left;">2014‑05‑13 11:57:57</td></tr><tr><th style="width: 20%; text-align: left;">Uses Template id</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.2</td><td style="text-align: left;">Include</td><td style="text-align: left;">[[File:Kyellow.png|16px]] CDA author</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.3.6</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Problem Organizer (2.0)</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Relationship</th><td style="text-align: left;" colspan="3">Specialization: template 2.16.840.1.113883.10.12.201 (<i>2005‑09‑07</i>)</td></tr><tr class="explabel" style="vertical-align: top;"><td style="width: 20em; text-align: left;">Example</td><td colspan="3" class="explabelgreen"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Example</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">section</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.8.1.2.3</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">22634-0</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Pathology report gross observation</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">title</span><span class="ppsign">&gt;</span><span class="pptext">Macroscopic observation</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) 0..* C --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entry</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entry</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">component</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">component</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Card</th><th style="width: 2em; text-align: left;">Conf</th><th style="text-align: left;">Description</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:section<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section</span></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><p class="TableEntry" style="margin-top:6.0pt;margin-right:3.7pt;margin-bottom: 0cm;margin-left:0cm;margin-bottom:.0001pt"><span lang="EN-US">This section SHALL contain a code element populated with these attributes:<span style="font-size: 12pt;"></span></span>
+
<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.3</td><th style="width: 20em; text-align: left;">Effective Date</th><td style="text-align: left;"> valid from 2014‑05‑13 11:57:09</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Draft</td><th style="width: 20em; text-align: left;">Version Label</th><td style="text-align: left;">2.0</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">MacroscopySection</td><th style="width: 20em; text-align: left;">Display Name</th><td style="text-align: left;">Macroscopic Observation Section</td></tr><td style="text-align: left;" colspan="4"><table class="treetable" id="templateDescTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Description</td></tr><tr><td><div><span lang="EN-US" style="mso-no-proof:no">The Macroscopic Observation section contains the description of the specimen(s) received or obtained by the laboratory (specimen type and state), the gross observation, links to gross images, if taken, processing information and tissue disposition (representative sampling and tissue submitted for additional studies or sent to biorepository.</span></div></td></tr></table></td><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Context</th><td style="text-align: left;" colspan="3">Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.3</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Label</th><td style="text-align: left;" colspan="3">PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section<br /></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Classification</th><td style="text-align: left;" colspan="3">CDA Section Level Template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Open/Closed</th><td style="text-align: left;" colspan="3">Open (other than defined elements are allowed)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Used by / Uses</th><td style="text-align: left;" colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Used by 0 transactions and 1 template, Uses 2 templates</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Used by</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.1.1</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Anatomic Pathology Structured Report Content Module (2.0)</td><td style="text-align: left;">2014‑05‑13 11:57:57</td></tr><tr><th style="width: 20%; text-align: left;">Uses</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.2</td><td style="text-align: left;">Include</td><td style="text-align: left;">[[File:Kyellow.png|14px]] CDA author IHE</td><td style="text-align: left;">2016‑06‑21 14:02:11</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.3.6</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Problem Organizer (2.0)</td><td style="text-align: left;">2015‑08‑13 10:24:55</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Relationship</th><td style="text-align: left;" colspan="3">Specialization: template 2.16.840.1.113883.10.12.201 <i> </i> (2005‑09‑07)</td></tr><tr class="explabel" style="vertical-align: top;"><td style="width: 20em; text-align: left;">Example</td><td colspan="3" class="explabelgreen"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Example</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">section</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.8.1.2.3</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">22634-0</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Pathology report gross observation</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">title</span><span class="ppsign">&gt;</span><span class="pptext">MACROSCOPIC OBSERVATION SECTION</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entry</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entry</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Card</th><th style="width: 2em; text-align: left;">Conf</th><th style="text-align: left;">Description</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:section<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section</span></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><p class="TableEntry" style="margin-top:6.0pt;margin-right:3.7pt;margin-bottom: 0cm;margin-left:0cm;margin-bottom:.0001pt">
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    <span lang="EN-US">This section SHALL contain a code element populated with these attributes:<span style="font-size: 12pt;">
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    </span>
 +
</span></p>
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<p class="TableEntry" style="margin-top:0cm;margin-right:3.7pt;margin-bottom: 0cm;margin-left:36.0pt;margin-bottom:.0001pt">
 +
    <span lang="EN-US">@code</span>
 +
    <span lang="EN-US">="22634-0" </span>
 
</p>
 
</p>
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<p class="TableEntry" style="margin-top:0cm;margin-right:3.7pt;margin-bottom: 0cm;margin-left:36.0pt;margin-bottom:.0001pt"><span lang="EN-US">@code</span><span lang="EN-US">="22634-0" </span>
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<p class="TableEntry" style="margin-top:0cm;margin-right:3.7pt;margin-bottom: 0cm;margin-left:36.0pt;margin-bottom:.0001pt">
 +
    <span lang="EN-US">@codeSystem</span>
 +
    <span lang="EN-US">="2.16.840.1.113883.6.1" </span>
 
</p>
 
</p>
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<p class="TableEntry" style="margin-top:0cm;margin-right:3.7pt;margin-bottom: 0cm;margin-left:36.0pt;margin-bottom:.0001pt"><span lang="EN-US">@codeSystem</span><span lang="EN-US">="2.16.840.1.113883.6.1" </span>
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<p class="TableEntry" style="margin-top:0cm;margin-right:3.7pt;margin-bottom: 0cm;margin-left:36.0pt;margin-bottom:.0001pt">
 +
    <span lang="EN-US">@displayName</span>
 +
    <span lang="EN-US">="Pathology report gross observation"  <span style="font-size: 12pt;">
 +
    </span>
 +
</span></p>
 +
<p class="MsoBodyText">
 +
    <span lang="EN-US">This section does not contain any subsection. The section SHALL contain a narrative block, represented by a <i>text</i> element, which renders the information to the human reader.</span>
 
</p>
 
</p>
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<p class="TableEntry" style="margin-top:0cm;margin-right:3.7pt;margin-bottom: 0cm;margin-left:36.0pt;margin-bottom:.0001pt"><span lang="EN-US">@displayName</span><span lang="EN-US">="Pathology report gross observation"  <span style="font-size: 12pt;"></span></span>
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<p class="MsoBodyText">
 +
    <span lang="EN-US">The section SHOULD contain as many Problem Organizer <i>entry</i> elements as there are problems or groups thereof to be described. These entries provide the machine-readable data corresponding to the narrative block.</span>
 
</p>
 
</p>
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<p class="MsoBodyText
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<p class="MsoBodyText">

Aktuelle Version vom 22. Januar 2018, 03:27 Uhr

Id1.3.6.1.4.1.19376.1.8.1.2.3Effective Date valid from 2014‑05‑13 11:57:09
StatusKyellow.png DraftVersion Label2.0
NameMacroscopySectionDisplay NameMacroscopic Observation Section
Description
The Macroscopic Observation section contains the description of the specimen(s) received or obtained by the laboratory (specimen type and state), the gross observation, links to gross images, if taken, processing information and tissue disposition (representative sampling and tissue submitted for additional studies or sent to biorepository.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.3
LabelPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 2 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.1.1ContainmentKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example
Example
<section>
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.3"/>  <code code="22634-0" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report gross observation"/>  <title>MACROSCOPIC OBSERVATION SECTION</title>  <text/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->
  <entry typeCode="COMP">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->
  </entry></section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … 1RPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
 Constraint

   This section SHALL contain a code element populated with these attributes:

@code ="22634-0"

@codeSystem ="2.16.840.1.113883.6.1"

@displayName ="Pathology report gross observation" 

This section does not contain any subsection. The section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.

The section SHOULD contain as many Problem Organizer entry elements as there are problems or groups thereof to be described. These entries provide the machine-readable data corresponding to the narrative block.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

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II1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
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CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
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CONF1 … 1F22634-0
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1 … 1FLOINC
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1 … 1FPathology report gross observation
Treetree.pnghl7:title
ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
 CONF
element content shall be "MACROSCOPIC OBSERVATION SECTION"
 Example<title>Macroscopic Observation</title>
Treetree.pnghl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
 Example
example for use case #1
<text>A. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)</text>
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
Author


Source: PaLM Suppl. APSR 2.0-3:  6.3.6.2


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0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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cs1 … 1FAUT
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor></author>
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uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
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TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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cs0 … 1FASSIGNED
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II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1
The author is either an assigned person or an authoring device.
Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
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0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
The name(s) SHALL be given.
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0 … 1FPSN
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0 … 1FINSTANCE
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PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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cs0 … 1FDEV
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cs0 … 1FINSTANCE
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SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 Example
represented organization for author as a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name></representedOrganization>
Included0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)
The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given.
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0 … 1FORG
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0 … 1FINSTANCE
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II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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0 … 1FPART
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II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
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CS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC)
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IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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0 … 1FORG
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0 … 1FINSTANCE
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II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treetree.pnghl7:entry
0 … *RSource: PaLM Suppl. APSR 2.0-3:  6.2.5.2
Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (2015‑08‑13 10:24:55)		PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
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Abgerufen von „https://wiki.hl7.de/index.php?title=1.3.6.1.4.1.19376.1.8.1.2.3/static-2014-05-13T115709&oldid=47738“