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

Id1.3.6.1.4.1.19376.1.3.10.9.43Effective Date valid from 2016‑10‑11 10:26:17
StatusKyellow.png DraftVersion Label2.0
NameAssessmentScoringItemAPSR2.0Display NameAssessment Scoring Item APSR 2.0
Description
Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF)

Supportive Observation entry template for describing the granular Items for a scoring system, e.g.Elston-Ellis-Score or Gleason Score
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.43
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 3 templates, Uses 5 templates
Used by as NameVersion
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
1.3.6.1.4.1.19376.1.3.10.4.4Link.pngKyellow.png Assessment Scales Observation for Scoring Systems APSR2 (2.0)2016‑10‑06 13:12:00
1.3.6.1.4.1.19376.1.3.10.4.3Link.pngKyellow.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
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 Percentage Score Item
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.9.43"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="444644009" displayName="Number fraction of estrogen receptors in neoplasm using immune stain (observable entity)" codeSystem="2.16.840.1.113883.6.96"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20170224122203"/>  </effectiveTime>  <value xsi:type="PQ" value="85" unit="%"/>  <interpretationCode code="A" displayName="abnormal" codeSystem="2.16.840.1.113883.5.83"/>  <referenceRange typeCode="REVF">
    <observationRange classCode="OBS" moodCode="EVN.CRT">
      <code code="" codeSystem="2.16.840.1.113883.5.4" displayName=""/>      <text/>      <effectiveTime value="20170224122203"/>      <value/>      <interpretation code="A" displayName="abnormal" codeSystem="2.16.840.1.113883.5.83"/>    </observationRange>  </referenceRange>  <methodCode code="0107" codeSystem="2.16.840.1.113883.5.84" displayName="Microscopy"/>  <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) 1..* M -->
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … *R(Ass...2.0)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1M(Ass...2.0)
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.9.43
Treetree.pnghl7:id
II0 … *R(Ass...2.0)
Treetree.pnghl7:code
CE (extensible)1 … 1M(Ass...2.0)
 CONF
shall be drawn from concept domain "<<395527009 | Microscopic specimen observable (observable entity) |"
 Example
for use case #1, Breast tubule formation
<code code="371470008" codeSystem="2.16.840.1.113883.6.96"/>
Treetree.pnghl7:text
ED0 … 1R(Ass...2.0)
Treetree.pnghl7:statusCode
CS (required)1 … 1M(Ass...2.0)
 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_TS0 … 1R(Ass...2.0)
Treetree.pnghl7:value
INT1 … 1RSingle numerical score item of a scoring system, e.g. "2"  for Breast tubule formation(Ass...2.0)
 Example
for use case #1
<value value="2"/>
Treetree.pnghl7:interpretationCode
CE (extensible)0 … 1R(Ass...2.0)
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)
Treetree.pnghl7:referenceRange
0 … 1R(Ass...2.0)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREVF
Treeblank.pngTreetree.pnghl7:observationRange
0 … 1R(Ass...2.0)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FOBS
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 … 1FEVN.CRT
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CD (extensible)1 … 1R(Ass...2.0)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.5.4 (Act Code)
Treeblank.pngTreeblank.pngTreetree.pnghl7:text
ED0 … 1R(Ass...2.0)
Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
TS0 … 1R(Ass...2.0)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
ANY1 … 1R(Ass...2.0)
Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretation
CD (extensible)0 … 1R(Ass...2.0)
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)
Treetree.pnghl7:methodCode
CE (extensible)0 … 1R(Ass...2.0)
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (2014‑03‑26)
Treetree.pnghl7:performer
II0 … *CPerforming 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)		(Ass...2.0)
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
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)		(Ass...2.0)
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)		(Ass...2.0)
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)		(Ass...2.0)
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.7']]
Included1 … *M 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
1 … *MRequired 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
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