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Version vom 3. Februar 2017, 12:28 Uhr

Dieses Material ist Teil des Leitfadens Pathologiebefund.
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Inhaltsverzeichnis

Foreword

This is a supplement to the IHE Pathology and Laboratory Medicine Technical Framework V7.0. Each supplement undergoes a process of public comment and trial implementation before being incorporated into the volumes of the Technical Frameworks.

This supplement is published on <Month XX, 2017> for Public Comment. Comments are invited and may be submitted at http://www.ihe.net/<domain>/<domain>comments.cfm. In order to be considered in development of the Trial Implementation version of the supplement, comments must be received by <Month XX, 201X>.

This supplement describes changes to the existing technical framework documents.

“Boxed” instructions like the sample below indicate to the Volume Editor how to integrate the relevant section(s) into the relevant Technical Framework volume. 

Replace Section X.X by the following:

Where the amendment adds text, make the added text bold underline. Where the amendment removes text, make the removed text bold strikethrough. When entire new sections are added, introduce with editor’s instructions to “add new text” or similar, which for readability are not bolded or underlined.

General information about IHE can be found at: http://www.ihe.net.

Information about the IHE Pathology and Laboratory Medicine domain can be found at: http://ihe.net/IHE_Domains.

Information about the structure of IHE Technical Frameworks and Supplements can be found at: http://ihe.net/IHE_Process and http://ihe.net/Profiles.

The current version of the IHE Technical Framework (if applicable) can be found at: http://ihe.net/Technical_Frameworks.


<Comments may be submitted on IHE Technical Framework templates any time at http://ihe.net/ihetemplates.cfm. Please enter comments/issues as soon as they are found. Do not wait until a future review cycle is announced.

Introduction to this Supplement

This supplement complements volume 1 of the PaLM technical framework with the description of the APSR 2.0 content profile, and volumes 3 and 4 with the bindings, content modules and value sets, which specify this profile.


Open Issues and Questions

None yet


Closed Issues

APSR-07 – Representing the hierarchy of specimens in an entry : This APSR supplement enables to represent the hierarchy of specimens at the CDA level 3. The operations on specimen and production of child specimens are tracked in the “Procedure Steps” section, which has a level 3 entry.

APSR-10 – Observation related to multiple specimens: For example tumor staging may require combining data from multiple specimens (e.g., a breast excision with positive margins followed by a re-excision with clear margins – in this case the tumor size may be a composite of measurements from both specimens. Another example is staging of ovarian carcinomas with multiple biopsies of pelvis, peritoneum, nodes, omentum, etc.). To accommodate these use cases, each problem organizer as well as each observation may reference any number of specimens using the <specimen> child element. Each of these references may point to a detailed description of the specimen, in the "procedure steps" section.

APSR-11 – Derivative specimens:Specimens derived from primary specimens for ancillary studies, which may be sent to a reference lab or done in another part of the same institution, are included in the scope of this profile. The results produced on a derived specimen are attached to this specimen in the report.

VOLUME 1 - PROFILES

10 Anatomic Pathology Structured Report (APSR) Profile

This content profile describes an anatomic pathology structured report (APSR) as a digital document to be shared or exchanged between pathology laboratories and other care providers and institutions.

Anatomic pathology structured reports document the findings on specimens removed from patients for diagnostic or therapeutic reasons. This information can be used for patient care, clinical research and epidemiology. Standardizing and computerizing anatomic pathology reports is necessary to improve the quality of reporting and to facilitate the exchange and reuse of the content of these reports.

This content profile describes a digital anatomic pathology report shared in a human-readable format, which may include images, and which also contains findings and observations in a machine-readable format, to facilitate the integration of these into the database of a consumer system, and to enable the application of automated reasoning to this content.

The scope of this IHE content profile covers all fields of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as cytopathology.

Goldsmith, J.D., et al., “Reporting guidelines for clinical laboratory reports in surgical pathology” Arch Pathol Lab Med, 2008. 132(10): p. 1608-16, is the first source of specification for this content profile. This article delineates the required, preferred, and optional elements which should be included in any report of surgical pathology.

This source is complemented by the “cancer checklists” produced by the College of American Pathologists, and by the “comptes rendus d’anatomopathologie : données minimales à renseigner pour une tumeur primitive” produced by the French society of pathology (SFP [1]) for the French cancer institute (INCa [www.e-cancer.fr]), and by the German "Guideline Pathology / Neuropathology" (formerly TM-30) of the Sector Committee Pathology for the implementation of DIN EN ISO/EC 17020.

This profile has also benefited from the guidance on cancer AP reports provided by the North-American Association of Central Cancer Registries; some of the example snippets captured in the profile leverage the NAACCR Standards for Cancer Registries, Volume V, Pathology Laboratory Electronic Reporting.

10.1 APSR Actors/Transactions

This section defines the actors, transactions, and/or content modules in this profile. General definitions of actors are given in the Technical Frameworks General Introduction Appendix A published here.

Figure 10.1-1 shows the actors directly involved in the APSR Profile and the direction that the content is exchanged.

A product implementation using this profile must group actors from this profile with actors from a workflow or transport profile to be functional. The grouping of the content module described in this profile to specific actors is described in more detail in the “Required Actor Groupings” section below.


Fig.4.1.-1.jpg

Figure 10.1-1 APSR Actor Diagram


Table 10.1-1 lists the content module(s) defined in the APSR profile. To claim support with this profile, an actor shall support all required content modules (labeled “R”) and may support optional content modules (labeled “O”).


Table 10.1-1: <Profile Acronym>Profile - Actors and Content Modules

Actors Content Modules Optionality Reference
Content

Creator

Anatomic Pathology Structured Report 1.3.6.1.4.1.19376.1.8.1.1.1

R PaLM TF-3: 6.3.1.2
Content

Consumer

Anatomic Pathology Structured Report 1.3.6.1.4.1.19376.1.8.1.1.1

R PaLM TF-3: 6.3.1.2


10.1.1 Actor Descriptions and Actor Profile Requirements

Most requirements are documented in Content Modules (Volume 3). This section documents any additional requirements on profile’s actors.

10.2 APSR Actor Options

Options that may be selected for each actor in this profile are listed in the table 10.2-1. These options are further detailed in PCC Technical Framework Volume 2 as indicated in the rightmost column.

Table 10.2-1 Anatomic Pathology Structured Report - Actors and Options

Actor Option Name Reference
Content

Creator

None
Content

Consumer

View Option (1)

Document Import Option (1)

Section Import Option (1)

PCC TF-2:3.1.1

PCC TF-2:3.1.2

PCC TF-2:3.1.3

Note 1: The Content Consumer Actor shall support at least one of these options.


10.3 APSR Required Actor Groupings

An Actor from this profile (Column 1) shall implement all of the required transactions and/or content modules in this profile in addition to all of the transactions required for the grouped actor (Column 2).

In some cases, required groupings are defined as at least one of an enumerated set of possible actors; this is designated by merging column one into a single cell spanning multiple potential grouped actors. Notes are used to highlight this situation.

Section 10.5 describes some optional groupings that may be of interest for security considerations and section 10.6 describes some optional groupings in other related profiles.

Table 10.3-1: Anatomic Pathology Structured Report - Required Actor Groupings

XD-LAB Actor Actor to be grouped with Reference Content Bindings Reference
Content

Creator

ITI XDS.b Document Source

OR

ITI XDM Portable Media Creator

OR

ITI XDR Document Source

ITI TF-1:10


ITI TF-1:16


ITI TF-1:15

Content

Consumer

ITI XDS.b Document Consumer

OR

ITI XDM Portable Media Consumer

OR

ITI XDR Document Recipient

ITI TF-1:10


ITI TF-1:16


ITI TF-1:15

Note 1: Each actor of APSR SHALL be grouped with at least one of the ITI actors listed in its table row.


10.4 APSR Overview

10.4.1 Concepts

This content profile represents a common digital document model applicable to any structured report for surgical pathology in all fields of anatomic pathology (cancers, benign neoplasms, non-neoplastic conditions) as well as for cytopathology.

This common model is composed of a header conveying the context of care (patient, care providers, pathologists, laboratories, order, act documented …) and a body. The body organizes the human-readable content of the report in a number of sections. Each section may also provide machine-readable content in a repeatable “entry” embedded in the section. This common model defines the order of appearance, cardinalities and internal structure of each section, and of each entry embedded in each section.

Figure 10.4.1-1 shows this general model applicable to any pathology digital report.

10.4.1-1 FM.jpeg

Figure 10.4.1-1 Common model for a digital anatomic pathology structured report

Note 1: The only section that is mandatory is the Diagnostic Conclusion section.

10.4.2 Use Cases

10.4.2.1 Use case #1: Single Report

Anatomic pathology order fulfilled by a pathology laboratory produces a report.


10.4.2.1.1 Single Report Use Case Description

A surgeon removes a breast tumor from a patient, requests the procedure “breast surgical specimen - pathological examination” and sends the specimen(s) to the anatomic pathology laboratory. Specimens) are accessioned by the anatomic pathology laboratory. The staff performs a macroscopic examination of the specimens ; gross imaging is performed if needed. The specimens are processed for microscopic examination and other special ancillary techniques or tissue banking if needed. During the imaging interpretation process, microscopic imaging is performed if needed. At the end of the interpretation process the pathologist queries the Content Creator application for the appropriate APSR template, fills the form, binds some relevant images and/or regions of interest to specific observations, validates and signs the digital report.

10.4.2.1.2 Single Report Process Flow

Intentionally left blank

10.4.2.1.3 Single Report Example

A. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY):

INVASIVE ADENOCARCINOMA OF THE BREAST. HISTOLOGIC TYPE: DUCTAL. NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3. TUBULE FORMATION SCORE: 2. NUCLEAR PLEOMORPHISM SCORE: 2. MITOTIC RATE SCORE: 1.

IN-SITU CARCINOMA: EQUIVOCAL.

BREAST CANCER BIOMARKER STUDIES: PARAFFIN BLOCK NUMBER: A1.


ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8).

PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED SCORE = 8).

DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR EXPRESSION OF

EPIDERMAL GROWTH FACTOR RECEPTOR.

HER2/NEU IMMUNOHISTOCHEMISTRY: POSITIVE (3+) FOR OVEREXPRESSION OF HER2/NEU

ONCOPROTEIN.

10.4.2.2 Use Case #2: Multi-step Report

Reporting includes multiple successive steps.


10.4.2.2.1 Multi-step Report Use Case Description

A surgeon removes a breast tumor from a patient, requests the procedure “breast surgical specimen - frozen sections & pathological examination”, and “breast surgical specimen - pathological examination” and sends the specimen(s) to the anatomic pathology laboratory.

Specimens are accessioned by the anatomic pathology department. The staff performs a macroscopic examination of the specimens, gross imaging is performed if needed. The specimens are processed for intraoperative observation if needed, and tissue banking if needed (e.g., for research purpose). During the imaging interpretation process of frozen sections, microscopic imaging is performed if needed. At the end of the interpretation process, the pathologist queries the Content Creator for the appropriate APSR template, fills the intraoperative observation section, binds some relevant images and/or regions of interest to specific observation(s) if needed, validates and signs (i.e., legally authenticates) the preliminary APSR.

The day after, the specimen(s) are processed for microscopic examination and other special ancillary techniques if needed. During the imaging interpretation process, microscopic imaging is performed if needed. At the end of the interpretation process, pathologist queries the Content Creator for the preliminary APSR, fills the form, binds some relevant images and/or regions of interest to specific observation(s), validates and signs (i.e., legally authenticates) the final APSR.


10.4.2.2.2 Multi-step Report Process Flow

Intentionally left blank


10.5 APSR Security Considerations

See Appendix A of PaLM TF-1.


10.6 APSR Cross Profile Considerations

Intentionally left blank


VOLUME 3 – CONTENT MODULES

1 Introduction

The content of this entire section is copied from section 1 of Volume 3 of PaLM TF.

1.1 Overview of the Anatomic Pathology Technical Framework

Integrating the Healthcare Enterprise (IHE) is an international initiative to promote the use of standards to achieve interoperability among health information technology (HIT) systems and effective use of electronic health records (EHRs). IHE provides a forum for care providers, HIT experts and other stakeholders in several clinical and operational domains to reach consensus on standards-based solutions to critical interoperability issues. The primary output of IHE is system implementation guides, called IHE Profiles. IHE publishes each profile through a well-defined process of public review and trial implementation and gathers profiles that have reached final text status into an IHE Technical Framework, of which this volume is a part. For more general information regarding IHE, refer to IHE International website. It is strongly recommended that, prior to reading this volume, the reader familiarizes themselves with the concepts defined in the IHE Technical Frameworks General Introduction.

1.2 Intended Audience

The intended audience of IHE Technical Frameworks Volume 3 is:

  • IT departments of healthcare institutions
  • Technical staff of vendors participating in the IHE initiative
  • Experts involved in standards development

1.3 Overview of Technical Framework Volume 3

Volume 3 is comprised of several distinct sections:

  • Section 1 provides background and reference material.
  • Section 2 presents the conventions used in this volume to define the content modules.
  • Section 3 provides an overview of Content Modules and the terminology used.
  • Section 4 is reserved for domain unique Content Module specifications.
  • Section 5 lists the namespaces and identifiers defined or referenced and the vocabularies defined or referenced herein.
  • Section 6 defines the PaLM domain’s HL7 V3 CDA Content Modules in detail.
  • Section 7 defines the PaLM domain’s DICOM content modules in detail.
  • Section 8 defines other types of content modules.

The appendices in Volume 3 provide clarification of technical details of the IHE data model and transactions. A glossary of terms and acronyms used in the IHE Technical Framework, including those from relevant standards, is provided in the IHE Technical Frameworks General Introduction. Due to the length of the document, some domains may divide Volume 3 into smaller volumes labeled 3a, 3b, etc. In this case, the Volume 3 appendices are gathered in Volume 3x. Code and message samples may also be stored on the IHE ftp server. In this case, explicit links to the ftp server will be provided in the transaction text.

1.4 Comment Process

IHE International welcomes comments on this document and the IHE initiative. They can be submitted by sending an email to the co-chairs and secretary of the Pathology and Laboratory Medicine domain committees at palm@ihe.net

1.5 Copyright Licenses

IHE International hereby grants to each Member Organization, and to any other user of these documents, an irrevocable, worldwide, perpetual, royalty-free, nontransferable, nonexclusive, non-sublicensable license under its copyrights in any IHE profiles and Technical Framework documents, as well as any additional copyrighted materials that will be owned by IHE International and will be made available for use by Member Organizations, to reproduce and distribute (in any and all print, electronic or other means of reproduction, storage or transmission) such IHE Technical Documents. The licenses covered by this Copyright License are only to those copyrights owned or controlled by IHE International itself. If parts of the Technical Framework are included in products that also include materials owned or controlled by other parties, licenses to use those products are beyond the scope of this IHE document and would have to be obtained from that other party.

1.5.1 Copyright of Base Standards

IHE technical documents refer to and make use of a number of standards developed and published by several standards development organizations. All rights for their respective base standards are reserved by these organizations. This agreement does not supersede any copyright provisions applicable to such base standards. Health Level Seven, Inc. has granted permission to IHE to reproduce tables from the HL7 standard. The HL7 tables in this document are copyrighted by Health Level Seven, Inc. All rights reserved. Material drawn from these documents is credited where used.

1.6 Trademark

IHE® and the IHE logo are trademarks of the Healthcare Information Management Systems Society in the United States and trademarks of IHE Europe in the European Community. They may only be used with the written consent of the IHE International Board Operations Committee, which may be given to a Member Organization in broad terms for any use that is consistent with the IHE mission and operating principles.

1.7 Disclaimer Regarding Patent Rights

Attention is called to the possibility that implementation of the specifications in this document may require use of subject matter covered by patent rights. By publication of this document, no position is taken with respect to the existence or validity of any patent rights in connection therewith. IHE International is not responsible for identifying Necessary Patent Claims for which a license may be required, for conducting inquiries into the legal validity or scope of Patents Claims or determining whether any licensing terms or conditions provided in connection with submission of a Letter of Assurance, if any, or in any licensing agreements are reasonable or non-discriminatory. Users of the specifications in this document are expressly advised that determination of the validity of any patent rights, and the risk of infringement of such rights, is entirely their own responsibility. Further information about the IHE International patent disclosure process including links to forms for making disclosures is available here. Please address questions about the patent disclosure process to the secretary of the IHE International Board: secretary@ihe.net

1.8 History of Document Changes

Content Modules for the APSR 2.0 Profile:

  • Reconfiguration of the Document content module
  • Reconfiguration of the Procedure step section content module
  • Introduction of the Additionally Specified Observation section content module
  • Reconfiguration of the entry content modules "Problem organizer" and "Specimen procedure steps"
  • Introduction of child element content modules "X-specimen identified", "UICC/AJCC-TNM observation", "ICD-O-3 observation", "Assessment scales observation"
  • Renewal and completion of value sets.

Transformation of a real-world use case into a valid APSR 2.0 xml instance.

Finishing the Supplement ready to public comment.

2 Conventions

This document has adopted the following conventions for representing the framework concepts and specifying how the standards upon which the IHE Technical Framework is based shall be applied.

2.1 Content Module Modeling and Profiling Conventions

In order to maintain consistent documentation, modeling methods for IHE content modules and profiling conventions for frequently used standards are maintained as an appendix in the IHE Technical Frameworks General Introduction. Methods described include the standards conventions DICOM, HL7 v2.x, HL7 Clinical Document Architecture (CDA) Documents, etc. These conventions are critical to understanding this volume and should be reviewed prior to reading this text.

2.2 Additional Standards Profiling Conventions

This section defines profiling conventions for standards which are not described in the IHE Technical Frameworks General Introduction.
Not Applicable.

3 Content Modules Overview and Terminology

In the future, an appendix to the IHE Technical Frameworks General Introduction will provide an overview of Content Modules. In the interim, information may be available here.
The Pathology and Laboratory Medicine content modules are listed in the table below:
Table 3-1: Pathology and Laboratory Medicine Content Modules

Content Module Acronym Type of Content Modules Semantic Status
XD-LAB CDA R2 medical document Clinical Laboratory Structured Report Final Text
APSR CDA R2 medical document Anatomic Pathology Structured Report Public Comment

4 IHE Pathology and Laboratory Medicine Bindings

4.1 Medical Document Binding to XDS, XDM and XDR

The bindings of the content modules of the PaLM domain leverage the bindings specified by the Patient Care Coordination domain, in PCC TF Volume 2, section 4, with the addition of the constraints specified below.

4.1.1 XDSDocumentEntry Metadata

4.1.1.1 XDSDocumentEntry.eventCodeList

Append this paragraph at the end of the section.

For the APSR content module, The XDSDocumentEntry.eventCodeList provides a means to index anatomic pathology reports by reportable conditions (e.g., certain types of tumors…) so as to facilitate later queries in a registry of shared clinical documents. The conclusions coded in the entry element of the Diagnostic Conclusion section are good candidates for this metadata.

4.1.1.2 XDSDocumentEntry.formatCode

Append this paragraph at the end of the section.

For the APSR content module, The XDSDocumentEntry.formatCode SHALL be urn:ihe:palm:apsr:2016
The associated codingScheme SHALL be 1.3.6.1.4.1.19376.1.2.3

4.1.1.3 XDSDocumentEntry.parentDocumentRelationship

Append this paragraph at the end of the section.

For the APSR content module XDSDocumentEntry.parentDocumentRelationship is constrained to the "RPLC" value. When there is a parent document the current document is a new version of the parent document, replacing it.

  • Note 1: A non-final anatomic pathology report published in an XDS infrastructure will likely be replaced afterwards by the final report. When this event occurs, the Content Creator Actor SHALL apply the following rules:
    • ClinicalDocument/setId SHALL have the same value in the new report as in the replaced report.
    • ClinicalDocument/versionNumber SHALL be incremented in the replacing report (i.e. the final one).
    • ClinicalDocument/relatedDocument@typeCode attribute SHALL be valued ”RPLC”
    • ClinicalDocument/relatedDocument/parentDocument/id in the new report SHALL be equal to ClinicalDocument/ id of the replaced document.

The Document Source Actor SHALL apply the following rules on XDSDocumentEntry metadata:

    • The final report SHALL be associated with the previously published one, using RPLC relationship and the previous report SHALL be “Deprecated” as described in ITI TF-2:4.1.6.1.
  • Note 2: A non-final report can also be replaced by a more recent, albeit still non-final report. The rules above also apply in this case.
  • Note 3: A final report can also be replaced by a corrective final report. The rules above also apply in this case.

5 Namespaces and Vocabularies

5.1 OID tree of PAT TF

1.3.6.1.4.1.19376.1.81.3.6.1.4.1.19376.1.8 is the OID of the former IHE Anatomic Pathology domain, whereas 1.3.6.1.4.1.19376.1.81.3.6.1.4.1.19376.1.3 is the OID for PaLM domain :

All exchangeable objects specified by these domains are identified by OIDs built on these roots:


Branch 1.3.6.1.4.1.19376.1.8.1 is dedicated to CDA Content Modules created by the AP domain 

       Sub-branch 1.3.6.1.4.1.19376.1.8.1.1 is the OID of the generic Document Content Module		
       Sub-branch 1.3.6.1.4.1.19376.1.8.1.2 is dedicated to Section Content Modules
       Sub-branch 1.3.6.1.4.1.19376.1.8.1.3 is dedicated to Entry Content Modules.
       Sub-branch 1.3.6.1.4.1.19376.1.8.1.3.6 is the OID of the Problem Organizer
       Sub-branch 1.3.6.1.4.1.19376.1.8.1.4 is dedicated to Element Content Modules	
       Sub-branch 1.3.6.1.4.1.19376.1.8.1.4.9 is the OID of the generic anatomic pathology (AP) observation template


Branch 1.3.6.1.4.1.19376.1.8.2 is dedicated to terminologies defined by AP domain 

       Sub-branch 1.3.6.1.4.1.19376.1.8.2.1 is dedicated to PathLex, BUT THIS TEMPORARY VOCABULARY IS NO LONGER USED

Branch 1.3.6.1.4.1.19376.1.8.5 is dedicated to Value Sets defined by AP domain.

Branch 1.3.6.1.4.1.19376.1.3.10 is dedicated to Templates newly defined by PaLM domain. 

       Sub-branch 1.3.6.1.4.1.19376.1.3.10.1 is dedicated to CDA Document Level Templates
       Sub-branch 1.3.6.1.4.1.19376.1.3.10.2 is dedicated to CDA Header Level Templates
       Sub-branch 1.3.6.1.4.1.19376.1.3.10.3 is dedicated to CDA Section Level Templates
       Sub-branch 1.3.6.1.4.1.19376.1.3.10.4 is dedicated to CDA Entry Level Templates
       Sub-branch 1.3.6.1.4.1.19376.1.3.10.9 is dedicated to CDA Template Fragments/Supporting Templates

Branch 1.3.6.1.4.1.19376.1.3.11 is dedicated to Value Sets newly defined by PaLM domain.

Branch 1.3.6.1.4.1.19376.1.8.9 is used to identify instances in the examples of AP content built by the PaLM domain.


Notes on other IHE OIDs used in the AP domain:

nn

5.2 Terminologies and controlled coded vocabularies

This section lists the terminologies and the coded vocabularies referenced by this Volume 3.

Table 5.2-1 Anatomic Pathology Terminologies and Coded Vocabularies

codeSystem codeSystemName Description Owner
2.16.840.1.113883.6.1 LOINC Logical Observation Identifier Names and Codes Regenstrief Institute
2.16.840.1.113883.6.8 UCUM Unified Code for Units of Measure Regenstrief Institute, and the UCUM Organization
2.16.840.1.113883.6.96 SNOMED-CT Systematized Nomenclature of Medicine – Clinical Terms IHTSDO
1.3.6.1.4.1.19376.1.5.3.2 IHEActCode Vocabulary defined by IHE PCC in PCC TF-2:5.1.2, used for representing annotation comments in the report IHE PCC
2.16.840.1.113883.5.4 Act Code Codesystem for Acts HL7
2.16.840.1.113883.5.6 ActClass Codesystem for Act Classes HL7
2.16.840.1.113883.5.1052 Act Site Codesystem for Act Sites HL7
2.16.840.1.113883.5.1065 ProcedureMethod Codesystem for Procedure Methods HL7
2.16.840.1.113883.5.111 Role Code Codesystem for Role Codes HL7
2.16.840.1.113883.5.129 SpecimenType Codesystem for Specimen Types HL7
2.16.840.1.113883.5.84 ObservationMethod A code system that provides additional detail about the means or technique used to ascertain the observation HL7
2.16.840.1.113883.6.3 ICD-10 International Classification of Diseases revision 10 WHO
2.16.840.1.113883.6.43 ICD-O-3 International Classification of Diseases for Oncology revision 3 WHO
1.2.840.10008.2.16.4 DICOM controlled vocabulary The meanings of codes defined in DICOM, either explicitly or by reference to another part of DICOM or an external reference document or standard [2] DICOM
2.16.840.1.113883.15.6 TNM 7th edition Internationally agreed-upon standards to describe and categorize cancer stages and progression http://www.uicc.org/resources/tnm Union for International Cancer Control (UICC) & American Joint Committee on Cancer (AJCC)
2.16.840.1.113883.15.7 TNM 6th edition Internationally agreed-upon standards to describe and categorize cancer stages and progression http://www.uicc.org/resources/tnm Union for International Cancer Control (UICC) & American Joint Committee on Cancer (AJCC)
2.16.840.1.113883.15.8 TNM 5th edition Internationally agreed-upon standards to describe and categorize cancer stages and progression http://www.uicc.org/resources/tnm Union for International Cancer Control (UICC) & American Joint Committee on Cancer (AJCC)
2.16.840.1.113883.6.4 ICD-10-PCS International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) WHO
1.2.276.0.76.5.464 OPS 2017 Code lists to describe and categorize surgeries and procedures, adapted from WHO ICPM for Germany DIMDI (WHO)
2.16.840.1.113883.6.174 OMIM Code lists to describe and categorize human genes. OMIM is a comprehensive, authoritative compendium of human genes and genetic phenotypes that is freely available and updated daily. OMIM Johns Hopkins University School of Medicine [3]
1.2.276.0.76.3.1.131.1.5.1 DKG Coding Scheme Internationally agreed-upon code lists to describe and categorize cancer grading systems, adapted for Germany [4] DKG (Deutsche Krebsgesellschaft)
1.2.276.0.76.5.336 Grading / Differentiation scheme Code lists to describe and categorize Tumor grading according ICD-O-3, adapted for Germany HL7.de
1.2.276.0.76.5.401 Localization scheme for distant metastases Code lists to describe and categorize localization of metastases according UICC, adapted for Germany HL7.de

5.3 Value Sets

The value sets defined or referenced by this Volume 3 of the IHE PaLM TF Suppl. are listed in Volume 4.

5.4 Namespaces

5.4.1 Namespace protecting extensions to the CDA schema

There is currently one single extension to the CDA.xsd schema used in PAT TF-3. This extension has been created by IHE LAB and is protected by this particular namespace in document instances: xmlns:lab="urn:oid:1.3.6.1.4.1.19376.1.3.2"


5.5 References to Content Modules built outside of IHE PAT TF

The Content Modules specified in this Volume 3 of the PAT TF leverage a number of Content Modules (currently CDA templates) produced and maintained by other groups, including other domains of IHE. Table 5.5-1 lists them.

Table 5.5-1 External Content Modules referenced by PAT TF-3

templateId Standard Definition Source of Specification
1.3.6.1.4.1.19376.1.5.3.1.3.1 CDA R2 Reason for referral IHE PCC TF-2:6.3.3.1.2
1.3.6.1.4.1.19376.1.5.3.1.3.4 CDA R2 History of present illness IHE PCC TF-2:6.3.3.2.1
1.3.6.1.4.1.19376.1.5.3.1.3.6 CDA R2 Active Problems IHE PCC TF-2:6.3.3.2.3
1.3.6.1.4.1.19376.1.5.3.1.4.2 CDA R2 Annotation Comment IHE PCC TF-2:6.3.4.6
1.3.6.1.4.1.19376.1.3.3.1.7 CDA R2 Laboratory Performer IHE PaLM TF-3:6.3.2.20
1.3.6.1.4.1.19376.1.3.3.1.6 CDA R2 Ordering Provider (ordering physician) IHE PaLM TF-3:6.3.2.17
1.3.6.1.4.1.19376.1.3.3.1.4 CDA R2 Intended Recipient IHE PaLM TF-3:6.3.2.14
1.3.6.1.4.1.19376.1.3.1.6 CDA R2 Laboratory Observation IHE PaLM TF-3:6.3.4.13

5.6 IHE code and formatCode for Anatomic Pathology Document Template

Merge the content of this section into the current section 5.1.1 of PaLM TF volume 3.

Any AP structured report SHALL be associated with the metadata typeCode = “11526-1”, which is the LOINC code for “Pathology study”.

The table below lists the format codes, template identifiers and media types used by the IHE Profiles specified in the PaLM Technical Framework. Note that the code system for these codes is 1.3.6.1.4.1.19376.1.2.3 as assigned by the ITI Domain for codes used for the purposes of cross-enterprise document sharing (XDS). For more information see XDS Coding System (1.3.6.1.4.1.19376.1.2.3).

Profile formatCode Media Type Template ID
XD-LAB urn:ihe:lab:xd-lab:2008 text/xml 1.3.6.1.4.1.19376.1.3.3
APSR urn:ihe:palm:apsr:2016 text/xml 1.3.6.1.4.1.19376.1.8.1.1.1

6 PaLM HL7 CDA Content Modules

6.1 Conventions

  • In all Content Modules specified in this section, the abbreviation “AP” stands for “Anatomic Pathology”.

6.2 Folder Modules

Intentionally left blank

6.3 Content Modules

This section defines each IHE Pathology and Laboratory Medicine Content Module in detail, specifying the standards used and the information defined.

6.3.1 CDA Document Content Modules

All persons (including the patient) and organizations mentioned in the CDA Document Content Modules SHALL include the elements name, addr and telecom.

6.3.1.1 Clinical Laboratory Report Content Module

Section unchanged, as in PaLM TF-3

6.3.1.2 Anatomic Pathology Structured Report Content Module

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. In other words, this is the generic template for any AP structured report.

The body of this Document Content Module has the hierarchy of sections and entries depicted by figure 4.1.2.1-1 in Volume 1.
The specification of this Document Content Module is built and published on Art-Decor

Id1.3.6.1.4.1.19376.1.8.1.1.1Effective Date valid from 2014‑05‑13 11:57:57
StatusKyellow.png DraftVersion Label2.0
NameAnatomicPathologyStructuredReportContentModuleDisplay NameAnatomic Pathology Structured Report Content Module
Description
Anatomic Pathology Structured Report Content Module. 


This document content module represents the generic set of constraints applied to any structured report for surgical pathology in all fields of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as for Cytopathology. 

The body of this Document Content Module specifies a common hierarchy of sections and entries depicted by figure 10.4.1-1 in Volume 1 IHE_PaLM_Suppl_APSR 2.0. The only mandatory section is the Diagnostic Conclusion Section. And the only mandatory entry is the Problem Organizer Entry below this section. 


ContextPathname /
LabelPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 20 templates
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.1IncludeKgreen.png Human Patient (2017)2017‑06‑07
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA author IHE2016‑06‑21 14:02:11
2.16.840.1.113883.10.12.103IncludeKgreen.png CDA dataEnterer2005‑09‑07
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
2.16.840.1.113883.10.12.104IncludeKgreen.png CDA custodian2005‑09‑07
1.3.6.1.4.1.19376.1.3.3.1.4IncludeKgreen.png XD-LAB Information Recipient (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.10.2.4IncludeKgreen.png XD-LAB LegalAuthenticator (2017)2016‑07‑05
1.3.6.1.4.1.19376.1.8.1.4.3IncludeKyellow.png CDA authenticator IHE2016‑07‑09 15:03:59
1.3.6.1.4.1.19376.1.3.3.1.6IncludeKgreen.png Ordering Provider (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.1IncludeKyellow.png CDA Participant Specimen Collector2016‑06‑13 14:21:13
1.3.6.1.4.1.19376.1.3.10.2.5IncludeKyellow.png CDA Participant Pertinent Insurance Information2017‑11‑13 16:52:30
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
2.16.840.1.113883.10.12.113IncludeKgreen.png CDA componentOf2005‑09‑07
1.3.6.1.4.1.19376.1.8.1.2.1ContainmentKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2ContainmentKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3ContainmentKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4ContainmentKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.3.10.3.1ContainmentKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.2.5ContainmentKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.2.6ContainmentKyellow.png Procedure Steps Section (2.0)2014‑05‑13 19:33:12
RelationshipSpecialization: template 2.16.840.1.113883.10.12.1 (2005‑09‑07)
Example
example for use case #1
<ClinicalDocument xsi:schemaLocation="urn:hl7-org:v3 infrastructure/cda/CDA_extended.xsd">
  <realmCode code="UV"/>  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>  <templateId root="1.3.6.1.4.1.19376.1.8.1.1.1"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_1" assigningAuthorityName="IHE PaLM Technical Committee"/>  <code code="60568-3" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology Synoptic report"/>  <title>Anatomic Pathology Structured Report - Breast Biopsy</title>  <effectiveTime value="201001041605-0500"/>  <confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25"/>  <languageCode code="en-US"/>  <setId root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008" assigningAuthorityName="IHE PaLM Technical Committee"/>  <versionNumber value="1"/>  <!-- Patient -->
  <recordTarget>
    <patientRole>
      <id extension="0411886319605719371016" root="1.3.6.1.4.1.19376.1.8.9.2"/>      <addr use="HP">
        <streetAddressLine>39 East Street</streetAddressLine>        <postalCode>69499</postalCode>        <city>Appleton</city>        <state>WI</state>        <country>United States</country>      </addr>      <telecom nullFlavor="NASK"/>      <patient>
        <name>
          <prefix>Miss</prefix>          <given>EVE</given>          <family qualifier="BR">ONEWOMAN</family>        </name>        <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>        <birthTime value="19710921"/>      </patient>    </patientRole>  </recordTarget>  <!-- one or more author(s) of the report, with authoring time -->
  <author>
    <templateId root="1.3.6.1.4.1.19376.1.8.1.4.2"/>    <time value="20100104131933-0500"/>    <assignedAuthor>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>      <addr nullFlavor="MSK"/>      <telecom value="tel:+33-602030499"/>      <assignedPerson>
        <name>
          <given>Marcel</given>          <family>Pathologist</family>          <suffix>Ph D</suffix>        </name>      </assignedPerson>      <representedOrganization>
        <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>        <name>CANCER INSTITUTE</name>        <telecom nullFlavor="MSK"/>        <addr nullFlavor="MSK"/>      </representedOrganization>    </assignedAuthor>  </author>  <!-- one or more transcriptionists, with transcription time -->
  <dataEnterer>
    <time value="20100104131720-0500"/>    <assignedEntity>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="A32"/>      <addr nullFlavor="MSK"/>      <telecom nullFlavor="MSK"/>      <assignedPerson>
        <name>
          <given>Adeline</given>          <family>Medsecret</family>        </name>      </assignedPerson>    </assignedEntity>  </dataEnterer>  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Body) APSR2' (dynamic), not used in use case #1 -->
  </informant>  <!-- The unique custodian of this document is the sending pathology lab that will administer it (further updates, deprecation) -->
  <custodian>
    <assignedCustodian>
      <representedCustodianOrganization>
        <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>        <name>CANCER INSTITUTE</name>        <telecom use="PUB" value="0466666666"/>        <addr>
          <streetAddressLine>38 Cramberry Street</streetAddressLine>          <postalCode>69499</postalCode>          <city>Appleton</city>          <state>WI</state>        </addr>      </representedCustodianOrganization>    </assignedCustodian>  </custodian>  <!-- One or more additional intended recipients (other than the ordering physician) -->
  <informationRecipient>
    <templateId root="1.3.6.1.4.1.19376.1.3.3.1.4"/>    <intendedRecipient>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="987"/>      <addr>
        <streetAddressLine>1600 Clifton Road</streetAddressLine>        <city>Atlanta</city>        <state>GA</state>        <postalCode>30333</postalCode>      </addr>      <telecom value="tel:404-639-3535"/>      <informationRecipient>
        <name>
          <family>WOULDLIKETOKNOW</family>          <given>Thomas</given>        </name>      </informationRecipient>    </intendedRecipient>  </informationRecipient>  <!-- The unique legal authenticator: The person assuming the final responsibility of the report and signing it -->
  <legalAuthenticator>
    <time value="20100104152503-0500"/>    <signatureCode code="S"/>    <assignedEntity>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>      <assignedPerson>
        <name>
          <given>Marcel</given>          <family>Pathologist</family>        </name>      </assignedPerson>    </assignedEntity>  </legalAuthenticator>  <!-- Zero or more additional content validator(s): pathologists having validated some part of the report -->
  <authenticator>
    <templateId root="1.3.6.1.4.1.19376.1.8.1.4.3"/>    <time value="20100104142503-0500"/>    <signatureCode code="S"/>    <assignedEntity>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567898"/>      <addr nullFlavor="MSK"/>      <telecom nullFlavor="MSK"/>      <assignedPerson>
        <name>
          <given>Jonas</given>          <family>Jones</family>          <prefix>MD</prefix>        </name>      </assignedPerson>    </assignedEntity>  </authenticator>  <!-- The ordering physician -->
  <participant typeCode="REF">
    <templateId root="1.3.6.1.4.1.19376.1.3.3.1.6"/>    <time>
      <high value="20091231"/>    </time>    <associatedEntity classCode="PROV">
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567892"/>      <addr nullFlavor="NASK"/>      <telecom value="tel:0147150000" use="EC"/>      <associatedPerson>
        <name>
          <prefix>Doctor</prefix>          <given>Eva</given>          <family>Surgeon</family>          <suffix>Ph D</suffix>        </name>      </associatedPerson>    </associatedEntity>  </participant>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.1 'CDA participant specimen collector' (dynamic) 0..* R, not used in use case #1 -->
  <!-- include template 1.3.6.1.4.1.19376.1.3.10.2.5 'CDA participant pertinent insurance information' (dynamic) 0..1 R, not used in use case #1 -->
  <!-- Identification of the order, extension is Order-ID -->
  <inFulfillmentOf>
    <order>
      <id root="1.3.6.1.4.1.19376.1.8.9.8" extension="12345"/>    </order>  </inFulfillmentOf>  <!-- Documented act(s): The pathology examination procedure, extension is Accession number -->
  <documentationOf>
    <serviceEvent>
      <id root="1.3.6.1.4.1.19376.1.8.9.9" extension="A7102400008"/>      <code code="371528001" displayName="Pathology report (record artifact)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>      <lab:statusCode code="completed"/>      <effectiveTime>
        <!-- Start: Date&time of reception of this order and the attached specimens -->
        <low value="200912300922-0500"/>        <!-- End -->
        <high value="201001041605-0500"/>      </effectiveTime>      <!-- Performing laboratory -->
      <performer typeCode="PRF">
        <templateId root="1.3.6.1.4.1.19376.1.3.3.1.7"/>        <time>
          <high value="201001041605-0500"/>        </time>        <assignedEntity>
          <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>          <representedOrganization>
            <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>            <name>CANCER INSTITUTE</name>            <telecom nullFlavor="MSK"/>            <addr nullFlavor="MSK"/>          </representedOrganization>        </assignedEntity>      </performer>    </serviceEvent>  </documentationOf>  <!-- include template 1.3.6.1.4.1.19376.1.3.1.9999.10.9.16 'RelatedDocument Parent Document' (dynamic) 0..1 R, not used in use case #1 -->
  <!-- Patient encounter: The patient stay in the hospital where the surgery was performed -->
  <componentOf>
    <encompassingEncounter>
      <id root="1.3.6.1.4.1.19376.1.8.9.7" extension="234567890"/>      <code code="ACUTE" displayName="inpatient acute"/>      <effectiveTime>
        <high value="2201001040735-0500"/>      </effectiveTime>      <location typeCode="LOC">
        <healthCareFacility classCode="SDLOC">
          <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="11223344"/>          <serviceProviderOrganization classCode="ORG" determinerCode="INSTANCE">
            <name>Surgery theater</name>            <asOrganizationPartOf>
              <wholeOrganization>
                <name>CANCER INSTITUTE</name>              </wholeOrganization>            </asOrganizationPartOf>          </serviceProviderOrganization>        </healthCareFacility>      </location>    </encompassingEncounter>  </componentOf>  <!-- Structured body -->
  <component typeCode="COMP" contextConductionInd="true">
    <structuredBody classCode="DOCBODY" moodCode="EVN">
      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.1 'Clinical Information Section' (2014-05-13T14:38:08) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.2 'Intraoperative Observation Section' (2014-05-13T19:29:16) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.3 'Macroscopic Observation Section' (2014-05-13T11:57:09) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.4 'Microscopic Observation Section' (2014-05-13T14:25:17) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.3.10.3.1 'Additionally Specified Observation Section' (2016-11-13T14:28:08) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.5 'Diagnostic Conclusion Section' (2014-05-13T19:31:26) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.6 'Procedure Steps Section' (2014-05-13T19:33:12) -->
      </component>    </structuredBody>  </component></ClinicalDocument>
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treetree.png@classCode
cs1 … 1FDOCCLIN
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1MThis element is identifying the set of constraints applied to the CDA R2 standard by this IHE specification of a AP report. The following templateId SHALL be present and valued as follows to indicate compliance with the APSR 2.0 content module specification.
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.1.1
Treetree.pnghl7:realmCode
CS (extensible)1 … 1MThis element SHALL be present and is valued from the RealmOfUse [2.16.840.1.113883.1.11.11050] subset, within the VocabularyDomainQualifier value set. In the international context of this profile used as it is without any further extension, the realm code SHALL be <realmCode code="UV"/> (universal).

Whenever a national extension has been defined and is used, the realm code SHALL identify this national extension.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treetree.pnghl7:typeId
II1 … 1MThis element is a technology-neutral explicit reference to the standard CDA R2. It SHALL be present and valued as follows:
ClinicalDocument/typeId@root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models);
ClinicalDocument.typeId@extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description).
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.1.3
Treeblank.pngTreetree.png@extension
st1 … 1FPOCD_HD000040
Treetree.pnghl7:id
II1 … 1MClinicalDocument/Id SHALL be present. It represents the unique instance identifier of the clinical document. The combination of the root and extension attributes SHALL provide a globally unique identifier, in accordance with CDA R2, without further constraints.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@root
uid1 … 1RHere the OID for PAT exemplary instances, in practice the OID of the LIS
Treeblank.pngTreetree.png@extension
st1 … 1RHere a hypothetical document ID, most often derived from the accession number
 ConstraintA report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report.

The unique id of the current revision of the report is carried by the id element, and is composed of 

  • id@root, which SHALL be an OID,
  • and optionally id@extension, which can be any string so that the concatenation of the two attributes root and extension provide a globally unique id, which identifies this release of the report. 
 Example
Report ID from use case #1
<id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_1" assigningAuthorityName="IHE PaLM Technical Committee"/>
Treetree.pnghl7:code
CE (required)1 … 1MClinicalDocument/code SHALL be present. The document type of this content module is always
<code code="60568-3"
codeSystem="2.16.840.1.113883.6.1"
displayName="Pathology Synoptic report"
codeSystemName="LOINC"/>



PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@code
CONF1 … 1F60568-3
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1FPathology Synoptic report
Treetree.pnghl7:title
ST1 … 1MThe APSR <title> SHALL be present. It is the local translation of the code@displayName.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 CONF
element content shall be "Anatomic Pathology Structured Report"
 Example
Report title from use case #1
<title>ANATOMIC PATHOLOGY REPORT - BREAST BIOPSY</title>
Treetree.pnghl7:effectiveTime
TS1 … 1MClinicalDocument/effectiveTime SHALL be present. It contains the creation date & time of the laboratory report as an electronic document. In case this is a new revision replacing a previous version (identified in parentDocument), this is the date & time of the new revision.
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treetree.pnghl7:confidentialityCode
CE (required)1 … 1MClinicalDocument/confidentialityCode SHALL be present in accordance with the HL7 CDA R2 standard.
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (2014‑06‑09)
Treetree.pnghl7:language​Code
CS (required)1 … 1MClinicalDocument/languageCode SHALL be present in accordance with the HL7 CDA R2 standard.
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (2014‑03‑26)
Treetree.pnghl7:setId
II1 … 1MClinicalDocument/setId SHALL be present to enable further updates of the clinical document. It is an identifier that is common across all revisions of this AP report.
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@root
uid1 … 1R
Treeblank.pngTreetree.png@extension
st1 … 1R
 ConstraintA report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report.
The setId element provides a globally unique identifier that is common across all successive revisions of the report. This identifier is similarly composed of setId@root, which SHALL be an OID, and optionally setId@extension. 
 Example
Report set ID from use case #1
<id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008" assigningAuthorityName="IHE PaLM Technical Committee"/>
Treetree.pnghl7:versionNumber
INT0 … 1RClinicalDocument/versionNumber MAY be present. As requested by the CDA standard, it is an integer value used as versioning.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@value
int1 … 1R
 ConstraintA report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report.

The version number of the current revision of the report is a positive integer (1, 2 …) provided in the versionNumber element.
 Example
Report version number for use case #1
<versionNumber value="1"/>
Included1 … 1M from 1.3.6.1.4.1.19376.1.3.3.1.1 Human Patient (2017‑06‑07)
The Patient.

The anatomic pathology report is related to ONE SINGLE patient. 

  • A patient SHALL be identified with at least one unique patientRole/Id.  
  • The patient address and telecom SHALL be provided (or null flavored).  
  • The patient identity SHALL provide AT LEASTthe patient full name, sex and date/time of birth. 
    Treetree.pnghl7:recordTarget
    		1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreetree.pnghl7:patientRole
    		1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL1 … *All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:patient
    		1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		PN1 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:administrative​Gender​Code
    		CE1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:birthTime
    		TS1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Included1 … *M from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
    The Author Content Module represents an author of the report. This element is repeatable. The sub-element  author/time  carries the date/time of the authoring action. 
       
       
    At least one ClinicalDocument/author SHALL be present with a time in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. The author/time element carries the date&time the AP report was produced. The AP report can be authored by a software system or by a person or by both.


    Source: PaLM Suppl.APSR 2.0‑3: 6.3.6.2


    Treetree.pnghl7:author
    		1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FAUT
     Example
    author is a person
    <author typeCode="AUT" contextControlCode="OP">
      <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
        <!-- ... -->
      </assignedAuthor>    </author>
    Treeblank.pngTreetree.pnghl7:templateId
    		1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
    Treeblank.pngTreetree.pnghl7:time
    		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
    Treeblank.pngTreetree.pnghl7:assignedAuthor
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FASSIGNED
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		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
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
    		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.
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPSN
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FDEV
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		cs0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
    		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.
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
    		CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPART
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
    		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)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    		IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		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
    Included0 … *R from 2.16.840.1.113883.10.12.103 CDA dataEnterer (2005‑09‑07)
    Transcriptionist
    Treetree.pnghl7:dataEnterer
    		0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreetree.png@typeCode
    		0 … 1FENT
    Treeblank.pngTreetree.png@context​Control​Code
    		0 … 1FOP
    Treeblank.pngTreetree.pnghl7:time
    		TS0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreetree.pnghl7:assignedEntity
    		1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treetree.pnghl7:informant
    		0 … *RZero or more informant MAY be mentioned in the header of the report. An informant is either an  assignedEntity  (a professional participating to the healthcare process, and who was assigned a defined role in that process) or a  relatedEntity  (a person who knows the patient and has provided relevant information concerning the patient). Hence the condition is either  assignedEntity  is present or  relatedEntity  is present. These two elements are defined in the content module “Informant”.


    Source: PaLM 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: 6.3.1.1 APSR clinical document content module
    Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.6']]
    Included1 … 1M from 2.16.840.1.113883.10.12.104 CDA custodian (2005‑09‑07)
    ClinicalDocument/custodian SHALL be present with an id in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. It represents the organization that is in charge of maintaining the AP report.
    Treetree.pnghl7:custodian
    		1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreetree.png@typeCode
    		0 … 1FCST
    Treeblank.pngTreetree.pnghl7:assignedCustodian
    		1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FASSIGNED
    Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Custodian​Organization
    		1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Included0 … *R from 1.3.6.1.4.1.19376.1.3.3.1.4 XD-LAB Information Recipient (2008‑08‑08)
    The Intended Recipient Content Module represents a healthcare provider,  

    other than the ordering physician, expecting to receive a copy of the report. This repeatable element informationRecipient of the CDA header is used to list the intended recipients who were known at the time the report was created and issued. 


    Source: PaLM TF-3: 6.3.2.14


    Treetree.pnghl7:information​Recipient
    		0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreetree.pnghl7:templateId
    		II1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.3.3.1.4
    Treeblank.pngTreetree.pnghl7:intended​Recipient
    		1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL1 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:information​Recipient
    		0 … 1Contains 1.3.6.1.4.1.19376.1.3.10.9.18 PlayingEntity or person with Name (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:received​Organization
    		0 … 1Contains 1.3.6.1.4.1.19376.1.3.10.9.13 Organization with Name, Addr, Telecom (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Included1 … 1M from 1.3.6.1.4.1.19376.1.3.10.2.4 XD-LAB LegalAuthenticator (2016‑07‑05)
    The Legal authenticator Content Module describes a pathologist having verified the content of the report, using the element legalAuthenticator.

    The report SHALL have one legal Authenticator


    Source: PaLM TF-3: 6.3.2.15

    Treetree.pnghl7:legalAuthenticator
    		1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreetree.pnghl7:time
    		TS1 … 1R

    The sub-element time carries the date&time this legal authentication took place.

    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreetree.pnghl7:signatureCode
    		CS1 … 1R

    The sub-element signatureCode carries the “signed” (S) status

    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.png@code
    		CONF0 … 1FS
    Treeblank.pngTreetree.pnghl7:assignedEntity
    		1 … 1R

    All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.

    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *R

    Constrained by this specification to require the presence of name, addr and telecom.

    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL1 … *R

    Constrained by this specification to require the presence of name, addr and telecom.

    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
    		0 … 1

    All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.


    Contains 1.3.6.1.4.1.19376.1.3.10.9.18 PlayingEntity or person with Name (DYNAMIC)    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
    		0 … 1

    All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.


    Contains 1.3.6.1.4.1.19376.1.3.10.9.13 Organization with Name, Addr, Telecom (DYNAMIC)    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Included0 … *R from 1.3.6.1.4.1.19376.1.8.1.4.3 CDA authenticator IHE (2016‑07‑09 15:03:59)

    The Content validator Content Module describes a pathologist having verified the content of the report, using the element authenticator. This element authenticator is used when the pathologist having verified the content of the report is distinct from the pathologist assuming the legal responsibility for this report, described in the legalAuthenticator element.

    The report MAY have zero or more Content Validators.


    Source: PaLM Suppl. APSR 2.0-3: 6.3.6.3


    Treetree.pnghl7:authenticator
    		0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FAUTHEN
    Treeblank.pngTreetree.pnghl7:templateId
    		1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.3
    Treeblank.pngTreetree.pnghl7:time
    		TS1 … 1RTime of validationPaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator
    Treeblank.pngTreetree.pnghl7:assignedEntity
    		0 … 1CAssignedPerson SHALL be given with name, representedOrganization MAY be given.
    Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (2005‑09‑07)    		PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator
    Included1 … 1R from 1.3.6.1.4.1.19376.1.3.3.1.6 Ordering Provider (2008‑08‑08)
       The Ordering Provider Content Module represents the physician who has submitted the specimen examination order to the anatomic pathology laboratory. As specified in PaLM TF-3, this physician is represented in the CDA header as a participant element with the typeCode attribute valued “REF”. The sub-element participant/time carries the date/time of issuance of the
           order.

       
    Source: PaLM TF-3: 6.3.2.17
    Treetree.pnghl7:participant
    		1 … 1RReferral Ordering PhysicianPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FREF
    Treeblank.pngTreetree.pnghl7:templateId
    		II1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.3.3.1.6
    Treeblank.pngTreetree.pnghl7:time
    		IVL_TS1 … 1RThis element represents the date and time the order was placed. Time MAY be present.PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreetree.pnghl7:associated​Entity
    		1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *RThe address of this person (referral ordering physician) SHALL be present.PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL.AT1 … *RThe telecom of this person (referral ordering physician) SHALL be present.PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
     Schematron assertroleKred.png error 
     testnot(hl7:assigned​Person) or hl7:assigned​Person/hl7:name 
     MessageThe <name> sub-element SHALL be present when <assignedPerson> present. 
    Treeblank.pngTreeblank.pngTreetree.pnghl7:associated​Person
    		0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:scoping​Organization
    		0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Included0 … *R from 1.3.6.1.4.1.19376.1.8.1.4.1 CDA Participant Specimen Collector (2016‑06‑13 14:21:13)
    The Specimen Collector Content Module is only used in case a specimen 

    provided as input to the AP act documented in this report, was collected by a different party than the ordering physician. In that case, this specimen collector is represented in the CDA header as a participant element with the typeCode attribute valued “DIST” and the sub-element participant/time carries the time period of the specimen collection.

    Source: PAT TF-3: 6.2.6.1


    Treetree.pnghl7:participant
    		0 … *RThe Specimen Collector Content Module is only used in case a specimen provided as input to the AP act documented in this report, was collected by a different party than the ordering physician. In that case, this specimen collector is represented in the CDA header as a participant element with the typeCode attribute valued “DIST” and the sub-element participant/time carries the time period of the specimen collection.
    		PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FDIST
    Treeblank.pngTreetree.pnghl7:templateID
    		II1 … 1MPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.1
    Treeblank.pngTreetree.pnghl7:time
    		IVL_TS1 … 1MSpecimen collection time


    The specimen collection time is an interval, which may be reduced to a point in time (see usage of data type IVL_TS).
    		PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreetree.pnghl7:associated​Entity
    		0 … 1RAt least one of the two elements

    associatedPerson and scopingOrganization must be present. Both may be present.  
    		PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs1 … 1FPROV
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL.AT1 … *RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.pnghl7:associated​Person
    		0 … *CPerson who collected the specimen.
    Only full name(s) SHALL be given.
    Contains 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)    		PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.pnghl7:scoping​Organization
    		0 … 1COrganization taking care for specimen collection.
    Identifiers, name, telecom, and address SHOULD be given.
    Contains 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)    		PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Included0 … 1R from 1.3.6.1.4.1.19376.1.3.10.2.5 CDA Participant Pertinent Insurance Information (2017‑11‑13 16:52:30)
    Key insurance information of the patient 
    Treetree.pnghl7:participant
    		0 … 1RInsurance information of the patient in context for reporting to cancer registries (in Germany)PaLM Suppl. 2.0‑3:6.3.6.13
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FHLD
    Treeblank.pngTreetree.pnghl7:templateId
    		II1 … *MPaLM Suppl. 2.0‑3:6.3.6.13
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.3.10.2.5
    Treeblank.pngTreetree.pnghl7:time
    		IVL_TS0 … 1Rtime shows the end of the current insurance period, e.g. end of the quartalPaLM Suppl. 2.0‑3:6.3.6.13
     Example<time>
      <high value="20171231"/></time>
    Treeblank.pngTreetree.pnghl7:associated​Entity
    		1 … 1MData of the insured personPaLM Suppl. 2.0‑3:6.3.6.13
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs1 … 1FPOLHOLD
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *RID(s) of the insured person (patient), e.g. ID of the insured, ID of the health card, etc.PaLM Suppl. 2.0‑3:6.3.6.13
    Treeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1Rstatus of the insured personPaLM Suppl. 2.0‑3:6.3.6.13
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
     Example<code code="SELF" codeSystem="2.16.840.1.113883.5.111" displayName="self">
      <translation code="1" codeSystem="2.16.840.1.113883.3.7.1.1" displayName="member"/></code>
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:translation
    		CV0 … 1Rfurther codes of the status of the insured person,


    e.g. for Germany from value set S_KBV_VERSICHERTENSTATUS 

    1.2.276.0.76.11.162    		PaLM Suppl. 2.0‑3:6.3.6.13
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … 1RPaLM Suppl. 2.0‑3:6.3.6.13
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … *RPaLM Suppl. 2.0‑3:6.3.6.13
    Treeblank.pngTreeblank.pngTreetree.pnghl7:associated​Person
    		0 … 1RData of the insured person, which may be different from the patient. 
    Contains 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)    		PaLM Suppl. 2.0‑3:6.3.6.13
    Treeblank.pngTreeblank.pngTreetree.pnghl7:scoping​Organization
    		1 … 1RData of the Insurance company, including the ID, the address data and the name.
    In Germany the ID is formed by the ID itself (@extension = so-called IKNR) and the OID for IKNR  (@root="1.2.276.0.76.4.5") in Germany.
    Contains 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)    		PaLM Suppl. 2.0‑3:6.3.6.13
    Treetree.pnghl7:inFulfillmentOf
    		0 … 1RThe inFulfillmentOf/order element MAY be present. It represents the Placer Order or the Placer Group that was fulfilled, the Id of which is carried by inFulfillmentOf/order/id.
    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FFLFS
    Treeblank.pngTreetree.pnghl7:order
    		1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs1 … 1FACT
    Treeblank.pngTreeblank.pngTreetree.png@moodCode
    		cs1 … 1FRQO
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *RPlacer order group ID or Placer order ID
    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treetree.pnghl7:documentationOf
    		1 … 1MDocumented act.PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FDOC
    Treeblank.pngTreetree.pnghl7:serviceEvent
    		1 … 1MThe AP report is documenting a service (documentationOf/serviceEvent) performed by a surgical pathology laboratory. The Laboratory Performer Content Module represents this laboratory, and is fully described in the sub-element 

    documentationOf/serviceEvent/performer.
    In case more than one laboratory contributed to a service, only the primary laboratory is in the CDA header, attached to the serviceEvent element, and the other (secondary) laboratories are described only in the sections of the report that they contributed to, in the body of the report.


    Source: PaLM TF3: 6.3.2.19

    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs1 … 1R
    Treeblank.pngTreeblank.pngTreetree.png@moodCode
    		cs1 … 1R
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *MID of the Act, i.e. Accession numberPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE (extensible)0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
     CONF
    @code shall be "PATREPE"
    @codeSystem shall be "2.16.840.1.113883.5.4"
    @codeSystemName shall be "HL7 ActCode"
    @displayName shall be "pathology report entry task"
    or
    @code shall be "371528001"
    @codeSystem shall be "2.16.840.1.113883.6.96"
    @codeSystemName shall be "SCT"
    @displayName shall be "Pathology report (record artifact)"
    Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    		IVL_TS0 … 1RUse of sub element documentationOf/serviceEvent/effectiveTime to document the time boundaries of events in the document is appropriate.
    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pngihe-lab:statusCode
    		CS (required)0 … 1R

       The statusCode below documentationOf/serviceEvent is an extension to the CDA R2 standard, added by PaLM TF-3 to distinguish a preliminary report (statusCode@code="active") from a final report (statusCode@code="completed"). 
    The statusCode sub element is  further described in section A.3 of PaLM TF-3. This sub-element is required. When it is not there, the documented Act is assumed to be completed and the report is assumed to be a final report.


    This extension to the standard is protected by a dedicated namespace associated in the ClinicalDocument element to the prefix lab:

    <Clinical Document  xmlns:lab="urn:oid:1.3.6.1.4.1.19376.1.3.2" … > 

    Source: PaLM TF3: 6.3.2.19

    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
     ConstraintThe statusCode@code="completed" is only applicable, if ALL content modules of the Clinical Document have the statusCode@code="completed", too, or have the statusCode@code="aborted".
     CONF
    The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.4 ActStatusActiveCompleted (2008‑08‑08)
     Schematron assertroleKred.png error 
     testhl7:serviceEvent/lab:statusCode[@code='completed'] 
     MessageStatus code of all Content Modules SHALL be "complete" or "aborted" 
    Treeblank.pngTreeblank.pngTreetree.pnghl7:performer
    		0 … *RContains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
    Treetree.pnghl7:relatedDocument
    		0 … 1R

    ClinicalDocument/relatedDocument/parentDocument

    This element SHALL be present in case of an update replacement of a previous report. In this case relatedDocument@typeCode attribute SHALL be valued "RPLC", the new report replacing the parent one.

    Note 1: A non-final AP structured report published in an XDS infrastructure will likely be replaced afterwards by the final report. When this event occurs, the Content Creator Actor SHALL apply the following rules:

    • ClinicalDocument/setId SHALL have the same value in the new report as in the replaced report.
    • ClinicalDocument/versionNumber SHALL be incremented in the replacing report (i.e., the final one).
    • ClinicalDocument/relatedDocument@typeCode attribute SHALL be valued ”RPLC”
    • ClinicalDocument/relatedDocument/parentDocument/id in the new report SHALL be equal to ClinicalDocument/ id of the replaced document.

    The Document Source Actor SHALL apply the following rules on XDSDocumentEntry metadata:

    • The final report SHALL be associated with the previously published one, using RPLC relationship and the previous report SHALL be “Deprecated” as described in ITI TF-2:4.1.6.1.

    Note 2: A non-final report can also be replaced by a more recent, albeit still non-final report. The rules above also apply in this case.

    Note 3: A final report can also be replaced by a corrective final report. The rules above also apply in this case.

    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FRPLC
     relatedDocument@typeCode attribute SHALL be valued "RPLC"
    Treeblank.pngTreetree.pnghl7:parentDocument
    		ANY1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … 1MSHALL be equal to ClinicalDocument/ id of the replaced document.
    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:setId
    		II1 … 1MSHALL have the same value in the new report as in the replaced report.
    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:versionNumber
    		INT0 … 1RSHALL have the same value as in the replaced report (when provided there).
    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Included0 … 1R from 2.16.840.1.113883.10.12.113 CDA componentOf (2005‑09‑07)
    The ClinicalDocument/componentOf/encompassingEncounter element MAY be present.


    It describes the encounter during which the reported AP observations were ordered. When present the encounter SHALL:

    • be identified with an id element: encompassingEncounter/id
    • The encounter SHALL have an effective time that represents the time interval (possibly still running, e.g., an inpatient current stay) of the encounter or a point in time at which the encounter took place (e.g., an outpatient consultation): encompassingEncounter/ effectiveTime

    The encounter MAY provide any number of encounter participants (encompassingEncounter/encounterParticipant/assignedEntity). When present, encounter participants SHALL be in accordance with the HL7 CDA R2 standard with a time and further constrained by this specification to require the presence of name, addr and telecom. Additionally, the encounter participant SHALL have a typeCode with one the values selected from the x_EncounterParticipant domain: The encounter MAY precise the patient location during this encounter. This is the healthcare facility in which the patient was located when the reported AP observations were ordered: encompassingEncounter/location/healthCareFacility. This healthcare facility can be represented as a physical place (e.g., room, floor, building, office) or as an organization (e.g., service, department, team) or both: healthCareFacility/location, healthCareFacility/serviceProviderOrganization.

    Treetree.pnghl7:componentOf
    		0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreetree.png@typeCode
    		0 … 1FCOMP
    Treeblank.pngTreetree.pnghl7:encompassing​Encounter
    		1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FENC
    Treeblank.pngTreeblank.pngTreetree.png@moodCode
    		0 … 1FEVN
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
     CONF
    The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC)
    Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    		IVL_TS1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:discharge​Disposition​Code
    		CE0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
     CONF
    shall be drawn from concept domain "EncounterDischargeDisposition"
    Treeblank.pngTreeblank.pngTreetree.pnghl7:responsible​Party
    		0 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		0 … 1FRESP
    Treeblank.pngTreeblank.pngTreetree.pnghl7:encounterParticipant
    		0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs1 … 1R
     CONF
    The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:time
    		IVL_TS0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assignedEntity
    		1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:location
    		0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		0 … 1FLOC
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:health​Care​Facility
    		1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FSDLOC
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
     CONF
    The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:location
    		0 … 1Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:service​Provider​Organization
    		0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treetree.pnghl7:component
    		1 … 1RBody of the CDA Clinical documentPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl1 … 1Ftrue
    Treeblank.pngTreetree.pnghl7:structuredBody
    		1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs1 … 1FDOCBODY
    Treeblank.pngTreeblank.pngTreetree.png@moodCode
    		cs1 … 1FEVN
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    		0 … 1RThe Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, clinical laboratory data, specimen(s) description, collection procedure, reason for anatomic pathology procedure.
    Contains 1.3.6.1.4.1.19376.1.8.1.2.1 Clinical Information Section (2014‑05‑13 14:38:08)    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.png where [@typeCode='COMP'] [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.2.1']]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    		bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    		0 … 1R
    Contains 1.3.6.1.4.1.19376.1.8.1.2.2 Intraoperative Observation Section (2014‑05‑13 19:29:16)    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.png where [@typeCode='COMP'] [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.2.2']]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    		bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    		0 … 1RThe Macroscopic Observation section contains the description of the specimen 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.
    Contains 1.3.6.1.4.1.19376.1.8.1.2.3 Macroscopic Observation Section (2014‑05‑13 11:57:09)    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.png where [@typeCode='COMP'] [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.2.3']]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    		bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    		0 … 1R

       The Microscopic Observation section contains optionally the histopathologic findings of the case and many laboratories use this section to record the results of histochemical and immunohistochemical stains.


    Contains 1.3.6.1.4.1.19376.1.8.1.2.4 Microscopic Observation Section (2014‑05‑13 14:25:17)    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.png where [@typeCode='COMP'] [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.2.4']]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    		bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    		0 … 1R

    The Additional Specific Observation section includes additional pathologic finding(s) and the results of ancillary study(ies) with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken. 


    Contains 1.3.6.1.4.1.19376.1.3.10.3.1 Additional Specified Observation Section (2016‑11‑13 14:28:08)    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.png where [@typeCode='COMP'] [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.3.1']]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    		bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    		1 … 1M

       The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.


    Contains 1.3.6.1.4.1.19376.1.8.1.2.5 Diagnostic Conclusion Section (2014‑05‑13 19:31:26)    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.png where [@typeCode='COMP'] [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.2.5']]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    		bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    		0 … 1R

       The Procedure steps section contains the description of tissue dissection: representative specimens and derived specimens dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, electron microscopy, etc.) or biorepository.


    Contains 1.3.6.1.4.1.19376.1.8.1.2.6 Procedure Steps Section (2014‑05‑13 19:33:12)    		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
    Treeblank.pngTreeblank.pngTreeblank.png where [@typeCode='COMP'] [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.2.6']]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    		bl1 … 1Ftrue
    6.3.1.2.1 General constraints that apply to APSR
    • When a section has a text element and one or more entry element, the content coded for machine-processing in the entries SHALL be completely transcribed into human-readable content in the text element.
    • Conversely the text element MAY contain pieces of information, which are not available in machine-readable format in any entry element of the section.
    • Information that is sent SHALL clearly identify distinctions between:

    None

    It is known with complete confidence that there are none. This indicates that the sender knows that there is no relevant information of this kind that can be sent.

    None Known

    None known at this time, but it is not known with complete confidence that none exist.

    Asked but unknown

    The information was requested but could not be obtained. Used mainly in the context where an observation was made but the result could not be determined.

    Unknown

    The information is not known, or is otherwise unavailable.

    Other, not specified

    The actual value does not belong to the assigned value set and is not reported at all by the author.

    Other, specify

    The actual value does not belong to the assigned value set and the author of the report provides this foreign value anyway.

    Not applicable

    No proper value is applicable in this context.

    Sections that are required to be present but have no information should use one of the above phrases where appropriate in the text element.

    Structural elements that are required but have no information shall provide a “nullFlavor” attribute coding the reason why the information is missing.

    Situation nullFlavor HL7 Definition
    Asked but unknown ASKU Information was sought but not found
    Unknown UNK A proper value is applicable, but not known
    Other, not specified OTH The actual value is not an element in the value domain of a variable. (e.g., concept not provided by required code system).
    Not applicable NA No proper value is applicable in this context
    Temporarily not available NAV Information is not available at this time but it is expected that it will be available later.


    The two situations “None” and “None known” represent effective values, which are part of the related value sets.

    The situation “Other, specify” can be handled in two ways in a coded data element:

    • Leaving empty the code attribute and providing the non-coded answer in the originalText attribute.
    • Providing a value coded from a different coding scheme, when the coding strength of the element is “CWE” (coded with extensions). The attributes code, displayName, codeSystem and codeSystemName then describe the foreign code.

    For ancillary techniques, the situation “ not performed” or “none performed” is represented by nullFlavor = NAV.


    6.3.1.2.2 Common structure for CDA APSR

    Figure 6.3.1.2.2-1 summarizes the common structure of the first six CDA APSR Section Content Modules specified here. Regarding the machine-readable part, the figure highlights the organization of entries within a section and of observations within an entry. Specific details such as the structure of sub-sections are not shown on this global picture.


    6.2.1.3-1-FO FM GH.jpeg

    Figure 6.3.1.2.2-1 CDA APSR: common structure of machine-readable content for CDA APSR Section Content Modules except Procedure Step Content Module

    Note 1: In order to facilitate a further de-identification process of CDA AP reports for some secondary use (biosurveillance, epidemiology…) the producer of an APSR SHOULD avoid populating any patient identification data (name, sex, birthdate, address …) into the body of the report (neither <entry> elements nor <text> elements). The appropriate location for patient identification data is the CDA header exclusively.

    Note 2: The AP sections are those shown on figure 10.4.1-1 of Volume 1.

    Note 3: The possible sub sections are shown on figure 10.4.1-1 of Volume 1.


    Figure 6.3.1.2.2-2 shows the common structure of the Procedure Step Content Module specified here, too.

    6.2.1.3-2-FO FM GH.jpeg

    Figure 6.3.1.2.2-2 CDA APSR: common structure of machine-readable content for Procedure Step Content Module

    6.3.2 Place Holder

    Intentionally left blank

    6.3.3 Place Holder

    Intentionally left blank

    6.3.4 CDA R2 <section> Content Modules

    6.3.4.1 Clinical Information <section> - 1.3.6.1.4.1.19376.1.8.1.2.1

    6.3.4.1.1 Definition and Purpose

    The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, reason for anatomic pathology procedure, clinical laboratory data, specimen collection procedure including target site, performer, specimen type, specimen(s) clinical description, and tumor site in case of a cancer. The only entry for this section is the Problem Organizer Entry module.

    6.3.4.1.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.2.1Effective Date valid from 2014‑05‑13 14:38:08
    StatusKyellow.png DraftVersion Label2.0
    NameClinicalInformationSectionDisplay NameClinical Information Section
    Description
    The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, reason for anatomic pathology procedure, clinical laboratory data, information about specimens collected in this case (including target site, performer, specimen type, specimen(s) clinical description, and tumor site in case of a cancer).
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.1
    LabelPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
    ClassificationCDA Section Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Used by / Uses
    Used by 0 transactions and 1 template, Uses 5 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
    1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
    1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA author IHE2016‑06‑21 14:02:11
    1.3.6.1.4.1.19376.1.5.3.1.3.1ContainmentKgreen.png IHE Reason for Referral Section (2014)2016‑09‑26 07:58:18
    1.3.6.1.4.1.19376.1.5.3.1.3.4ContainmentKgreen.png IHE History of Present Illness Section (2014)2013‑01‑31
    1.3.6.1.4.1.19376.1.5.3.1.3.6ContainmentKgreen.png IHE Active Problems Section (2014)2015‑10‑05 16:02:07
    RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
    Example
    generated example
    <section classCode="DOCSECT" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.8.1.2.1"/>  <code code="22636-5" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report relevant history"/>  <title>CLINICAL INFORMATION SECTION</title>  <text/>  <languageCode/>  <entry xsi:type="ANY" typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->
      </entry>      <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->
      <component>
        <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.1 'IHE Reason for Referral Section' (2016-09-26T07:58:18) -->
      </component>      <component>
        <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.4 'History of Present Illness Section' (2013-01-31T00:00:00)
    -->
      </component>      <component>
        <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.6 'IHE Active Problems Section' (2015-10-05T16:02:07) -->
      </component>    </section>
    ItemDTCardConfDescriptionLabel
    hl7:section
    		0 … 1RPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
    Treetree.png@classCode
    		cs0 … 1FDOCSECT
    Treetree.png@moodCode
    		cs0 … 1FEVN
     Constraint

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

    @code="22636-5" 

    @codeSystem="'2.16.840.1.113883.6.1" 

    @displayName=" Pathology report relevant history”  

    This 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 MAY contain a number of elements component/section introducing sub-sections, each of these sub-sections providing a particular type of clinical information.

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

    Treetree.pnghl7:templateId
    		II1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.1
    Treetree.pnghl7:code
    		CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
    Treeblank.pngTreetree.png@code
    		CONF1 … 1F22636-5
    Treeblank.pngTreetree.png@codeSystem
    		1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
    Treeblank.pngTreetree.png@codeSystemName
    		1 … 1FLOINC
    Treeblank.pngTreetree.png@displayName
    		1 … 1FPathology report relevant history
    Treetree.pnghl7:title
    		ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
     CONF
    element content shall be "CLINICAL INFORMATION SECTION"
     Example<title>CLINICAL INFORMATION</title>
    Treetree.pnghl7:text
    		SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
     Example<text> Tissue submitted: left breast biopsy and apical axillary tissue </text>
    Treetree.pnghl7:language​Code
    		CS0 … 1PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
     CONF
    The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (2014‑03‑26)
    Treetree.pnghl7:entry
    		ANY0 … *RProblem organizer
    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: 6.3.4.1 Clinical information section
    Treeblank.png where [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]]
    Treeblank.pngTreetree.png@typeCode
    		cs0 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
    Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
    Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2
    Treetree.pnghl7:author
    		0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FAUT
     Example
    author is a person
    <author typeCode="AUT" contextControlCode="OP">
      <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
        <!-- ... -->
      </assignedAuthor>    </author>
    Treeblank.pngTreetree.pnghl7:templateId
    		1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
    Treeblank.pngTreetree.pnghl7:time
    		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
    Treeblank.pngTreetree.pnghl7:assignedAuthor
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FASSIGNED
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		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
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
    		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.
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPSN
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FDEV
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		cs0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
    		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.
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
    		CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPART
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
    		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)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    		IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		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:component
    		0 … 1Subsection

    Source: PCC TF-2: 6.3.3.1.1
    Contains 1.3.6.1.4.1.19376.1.5.3.1.3.1 IHE Reason for Referral Section (2016‑09‑26 07:58:18)    		PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
    Treeblank.png where [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.5.3.1.3.1']]]
    Treetree.pnghl7:component
    		0 … 1Subsection



    Source: PCC TF-2: 6.3.3.2.1
    Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 IHE History of Present Illness Section (2013‑01‑31)    		PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
    Treeblank.png where [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.5.3.1.3.4']]]
    Treetree.pnghl7:component
    		0 … 1Subsection

    Source: PCC TF-2: 6.3.3.2.3
    Contains 1.3.6.1.4.1.19376.1.5.3.1.3.6 IHE Active Problems Section (2015‑10‑05 16:02:07)    		PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
    Treeblank.png where [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.5.3.1.3.6'] and hl7:templateId [@root='2.16.840.1.113883.10.20.1.11']]]

    6.3.4.2 Intraoperative Observation <section> - 1.3.6.1.4.1.19376.1.8.1.2.2

    6.3.4.2.1 Definition and Purpose

    The Intraoperative Observation section contains an intraoperative diagnosis for each specimen examined, the specimen identification and description, intraoperative observation procedure description (frozen section, gross examination, intraoperative cytology) and derived specimen dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, and electron microscopy). The only entry for this section is the Problem Organizer Entry module.

    6.3.4.2.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.2.2Effective Date valid from 2014‑05‑13 19:29:16
    StatusKyellow.png DraftVersion Label2.0
    NameIntraoperativeObservationSectionDisplay NameIntraoperative Observation Section
    Description
    The Intraoperative Observation section contains an intraoperative diagnosis for each specimen examined, the specimen identification and description, intraoperative observation procedure description (frozen section, gross examination, intraoperative cytology) and derived specimen dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, and electron microscopy).
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.2
    LabelPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative 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
    generated example
    <section classCode="DOCSECT" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.8.1.2.2"/>  <code code="83321-0" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report intraoperative observation in Specimen Document"/>  <title>INTRAOPERATIVE OBSERVATION SECTION</title>  <text/>  <languageCode/>  <!-- 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" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' Problem Organizer (2015-08-13T10:24:55) -->
      </entry>    </section>
    ItemDTCardConfDescriptionLabel
    hl7:section
    		0 … 1RPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
    Treetree.png@classCode
    		cs1 … 1FDOCSECT
    Treetree.png@moodCode
    		cs1 … 1FEVN
     Constraint

       This 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 observed. These entries provide the machine-readable data corresponding to the narrative block.

    This section does not contain any subsection.

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

    Treetree.pnghl7:templateId
    		II1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.2
    Treetree.pnghl7:code
    		CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
    Treeblank.pngTreetree.png@code
    		CONF1 … 1F83321-0
    Treeblank.pngTreetree.png@codeSystem
    		1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
    Treeblank.pngTreetree.png@codeSystemName
    		1 … 1FLOINC
    Treeblank.pngTreetree.png@displayName
    		1 … 1FPathology report intraoperative observation in Specimen Document
    Treetree.pnghl7:title
    		ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
     CONF
    element content shall be "INTRAOPERATIVE OBSERVATION SECTION"
    Treetree.pnghl7:text
    		SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
     Example
    Intraoperative observation
    <text>Frozen section diagnosis of infiltrating duct carcinoma, left breast</text>
    Treetree.pnghl7:language​Code
    		CS0 … 1PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
     CONF
    The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (2014‑03‑26)
    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: 

    6.2.6.2


    Treetree.pnghl7:author
    		0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FAUT
     Example
    author is a person
    <author typeCode="AUT" contextControlCode="OP">
      <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
        <!-- ... -->
      </assignedAuthor>    </author>
    Treeblank.pngTreetree.pnghl7:templateId
    		1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
    Treeblank.pngTreetree.pnghl7:time
    		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
    Treeblank.pngTreetree.pnghl7:assignedAuthor
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FASSIGNED
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		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
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
    		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.
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPSN
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FDEV
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		cs0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
    		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.
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
    		CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPART
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
    		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)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    		IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		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: PAT TF-3:6.2.6.8

    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: 6.3.4.2 Intraoperative observation section
    Treeblank.png where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue

    6.3.4.3 Macroscopic Observation <section> - 1.3.6.1.4.1.19376.1.8.1.2.3

    6.3.4.3.1 Definition and Purpose

    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. The only entry for this section is the Problem Organizer Entry module.

    6.3.4.3.2 Specification and Example
    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.

    Treetree.pnghl7:templateId
    		II1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.3
    Treetree.pnghl7:code
    		CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
    Treeblank.pngTreetree.png@code
    		CONF1 … 1F22634-0
    Treeblank.pngTreetree.png@codeSystem
    		1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
    Treeblank.pngTreetree.png@codeSystemName
    		1 … 1FLOINC
    Treeblank.pngTreetree.png@displayName
    		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


    Treetree.pnghl7:author
    		0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FAUT
     Example
    author is a person
    <author typeCode="AUT" contextControlCode="OP">
      <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
        <!-- ... -->
      </assignedAuthor>    </author>
    Treeblank.pngTreetree.pnghl7:templateId
    		1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
    Treeblank.pngTreetree.pnghl7:time
    		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
    Treeblank.pngTreetree.pnghl7:assignedAuthor
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FASSIGNED
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		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
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
    		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.
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPSN
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
    		0 … 1CPaLM 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
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
    		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.
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
    		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
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPART
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
    		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)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    		IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		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
    Treeblank.png where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue

    6.3.4.4 Microscopic Observation <section> - 1.3.6.1.4.1.19376.1.8.1.2.4

    6.3.4.4.1 Definition and Purpose

    The Microscopic Observation section contains optionally the histopathologic findings of the case and many laboratories use this section to record the results of histochemical and immunohistochemical stains.The only entry for this section is the Problem Organizer Entry module.

    6.3.4.4.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.2.4Effective Date valid from 2014‑05‑13 14:25:17
    StatusKyellow.png DraftVersion Label2.0
    NameMicroscopySectionDisplay NameMicroscopic Observation Section
    Description
    The Microscopic Observation section contains optionally the histopathologic findings of the case and of all of the derived specimens. This section should be used to record the results of histochemical and immunohistochemical stains and of image-based molecular methods.
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.4
    LabelPaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic 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="1.3.6.1.4.1.19376.1.8.1.2.4"/>  <code code="22635-7" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report microscopic observation"/>  <title>MICROSCOPIC 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>
        <!-- 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: 6.3.4.4 Microscopic observation section
     Constraint

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

    @code ="22635-7"

    @codeSystem ="2.16.840.1.113883.6.1"

    @displayName ="Pathology report microscopic observation" 

    This 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.

    This section does not contain any subsections. 

    Treetree.pnghl7:templateId
    		II1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.4
    Treetree.pnghl7:code
    		CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
    Treeblank.pngTreetree.png@code
    		CONF1 … 1F22635-7
    Treeblank.pngTreetree.png@codeSystem
    		1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
    Treeblank.pngTreetree.png@codeSystemName
    		1 … 1FLOINC
    Treeblank.pngTreetree.png@displayName
    		1 … 1FPathology report microscopic observation
    Treetree.pnghl7:title
    		ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
     CONF
    element content shall be "MICROSCOPIC OBSERVATION SECTION"
     Example<title>MICROSCOPIC OBSERVATION SECTION</title>
    Treetree.pnghl7:text
    		SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
     Example
    example from use case#1
    <text>
       INVASIVE ADENOCARCINOMA OF THE BREAST.  <br/>  
    HISTOLOGIC TYPE: DUCTAL.      <br/>  
    NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3.
      <list>
        <item>TUBULE FORMATION SCORE: 2.</item>    <item>NUCLEAR PLEOMORPHISM SCORE: 2.</item>    <item>MITOTIC RATE SCORE: 1.</item>  </list>      
    IN-SITU CARCINOMA: EQUIVOCAL.      <br/>  <br/>  
    BREAST CANCER BIOMARKER STUDIES:
      <list>
        <item>PARAFFIN BLOCK NUMBER: A1.</item>    <item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED
    SCORE = 8, Allred Percentage Score = 5, Allred Staining Score = 3).    </item>        <item>PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED
    SCORE = 8).    </item>        <item>DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR
    EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.    </item>        <item>HER2/NEU IMMUNOHISTOCHEMISTRY: EQUIVOCAL (2+) FOR OVEREXPRESSION
    OF HER2/NEU ONCOPROTEIN.    </item>        <item>HER2/NEU FISH RESULTS: NOT AMPLIFIED.</item>  </list>    </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


    Treetree.pnghl7:author
    		0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FAUT
     Example
    author is a person
    <author typeCode="AUT" contextControlCode="OP">
      <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
        <!-- ... -->
      </assignedAuthor>    </author>
    Treeblank.pngTreetree.pnghl7:templateId
    		1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
    Treeblank.pngTreetree.pnghl7:time
    		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
    Treeblank.pngTreetree.pnghl7:assignedAuthor
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FASSIGNED
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		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
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
    		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.
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPSN
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FDEV
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		cs0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
    		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.
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
    		CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPART
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
    		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)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    		IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		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 … *RProblem organizer entry


    Source: 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: 6.3.4.4 Microscopic observation section
    Treeblank.png where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue

    6.3.4.5 Additional Specified Observation <section> - 1.3.6.1.4.1.19376.1.3.10.3.1

    6.3.4.5.1 Definition and Purpose

    The Additional Specified Observation section includes additional pathologic finding(s) and the results of ancillary studies with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken. The only entry for this section is the Problem Organizer Entry module.

    6.3.4.5.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.3.10.3.1Effective Date valid from 2016‑11‑13 14:28:08
    StatusKyellow.png DraftVersion Label2.0
    NameAdditionalSpecifiedObservationSectionDisplay NameAdditional Specified Observation Section
    Description
    Template CDA Section (prototype, directly derived from POCD_RM000040 MIF)

    The Additional Specified Observation section includes additional pathologic finding(s) and the results of ancillary study(yes) with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken.  Further CDA content section modules as subsections are allowed. 
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.3.1
    LabelPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified 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
    RelationshipAdaptation: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
    Example
    generated example
    <section classCode="DOCSECT" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.3.10.3.1"/>  <code code="xxxxx-x" codeSystem="2.16.840.1.113883.6.1" displayName="specified observation"/>  <title>ADDITIONAL SPECIFIED OBSERVATION SECTION</title>  <text/>  <author>
        <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016‑06‑21 14:02:11) -->
      </author>      <entry typeCode="COMP" contextConductionInd="true">
        <!-- 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 … *RPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
    Treetree.png@classCode
    		cs0 … 1FDOCSECT
    Treetree.png@moodCode
    		cs0 … 1FEVN
     Constraint

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

    @code ="xxxxx-x" (specific for the additional specified observation)

    @codeSystem ="2.16.840.1.113883.6.1" 

    @displayName ="Pathology report yyyyy (specific) observation"  

    This section SHALL contain a narrative block, represented by a textelement, 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.

    This section MAY contain subsections. 

    Treetree.pnghl7:templateId
    		II1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.3.10.3.1
    Treetree.pnghl7:code
    		CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
     ConstraintThe LOINC code SHALL be chosen according the specified observation type
    Treeblank.pngTreetree.png@code
    		CONF1 … 1Fxxxxx-x
    Treeblank.pngTreetree.png@codeSystem
    		1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
    Treeblank.pngTreetree.png@codeSystemName
    		1 … 1FLOINC
    Treeblank.pngTreetree.png@displayName
    		1 … 1Fspecified observation
    Treetree.pnghl7:title
    		ST1 … 1RTitle of the specified observationPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
     CONF
    element content shall be "ADDITIONAL SPECIFIED OBSERVATION SECTION"
     Example
    MP observation
    <text>MOLECULAR PATHOLOGY OBSERVATION SECTION</text>
    Treetree.pnghl7:text
    		SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
    Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
    Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2 
    Treetree.pnghl7:author
    		0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FAUT
     Example
    author is a person
    <author typeCode="AUT" contextControlCode="OP">
      <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
        <!-- ... -->
      </assignedAuthor>    </author>
    Treeblank.pngTreetree.pnghl7:templateId
    		1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
    Treeblank.pngTreetree.pnghl7:time
    		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
    Treeblank.pngTreetree.pnghl7:assignedAuthor
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FASSIGNED
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		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
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
    		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.
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPSN
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
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    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: 6.3.4.5 Addtional specified observation section
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    6.3.4.6 Diagnostic Conclusion <section> - 1.3.6.1.4.1.19376.1.8.1.2.5

    6.3.4.6.1 Definition and Purpose

    The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen sample or group of specimen samples are reported separately. This section may include diagrams and still images or virtual slides, if taken. In case of cancer, this section may also include a the cancer checklist. The only entry for this section is the Problem Organizer Entry module.

    6.3.4.6.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.2.5Effective Date valid from 2014‑05‑13 19:31:26
    StatusKyellow.png DraftVersion Label2.0
    NameDiagnosticConclusionSectionDisplay NameDiagnostic Conclusion Section
    Description
    The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.
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    LabelPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
    ClassificationCDA Section Level Template
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    Uses as NameVersion
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    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
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    ItemDTCardConfDescriptionLabel
    hl7:section
    		1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
    Treetree.png@classCode
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    @codeSystem ="2.16.840.1.113883.6.1"

    @displayName ="Pathology report diagnosis" 

    This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.

    The section SHALL contain as many Problem Organizer entry elements as there are problems or groups thereof investigated. Each entry provides machine-readable data.

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

    Treetree.pnghl7:templateId
    		II1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
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    Treeblank.pngTreetree.png@code
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    		ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
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    element content shall be "DIAGNOSTIC CONCLUSION SECTION"
    Treetree.pnghl7:text
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     Example
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    <text>
      <paragraph> A1. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)
    </paragraph>      
    INVASIVE ADENOCARCINOMA OF THE BREAST.      <br/>  
    HISTOLOGIC TYPE: DUCTAL.      <br/>   NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3.
      <list>
        <item>TUBULE FORMATION SCORE: 2.</item>    <item>NUCLEAR PLEOMORPHISM SCORE: 2.</item>    <item>MITOTIC RATE SCORE: 1.</item>  </list>      
    ICD-O-CLASSIFICATION: C50.3 M8500/31      <br/>  
    IN-SITU CARCINOMA: EQUIVOCAL.      <br/>  <br/>  
    BREAST CANCER BIOMARKER STUDIES:
      <list>
        <item>PARAFFIN BLOCK NUMBER: A1.</item>    <item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED
    SCORE = 8, Percentage stained tumor cells = 85%, Allred Staining Score = 3).    </item>        <item>PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED
    SCORE = 8).    </item>        <item>DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR
    EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.    </item>        <item>HER2/NEU IMMUNOHISTOCHEMISTRY: EQUIVOCAL (2+) FOR OVEREXPRESSION
    OF HER2/NEU ONCOPROTEIN.    </item>        <item>HER2/NEU FISH RESULTS: NOT AMPLIFIED.</item>  </list>    </text>
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    Author
             
    Source: PaLM Suppl. APSR 2.0-3: 
         6.3.6.2
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    Treeblank.pngTreetree.pnghl7:time
    		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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    Included0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
    The name(s) SHALL be given.
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPSN
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
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    <representedOrganization classCode="ORG" determinerCode="INSTANCE">
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        <!-- ... -->
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    Included0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)
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    		II0 … *RPaLM 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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     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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    		II0 … *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
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    Treetree.pnghl7:entry
    		0 … 1CSource: PaLM Suppl. APSR 2.0-3: 6.2.5.4

    Contains 1.3.6.1.4.1.19376.1.3.10.4.5 CDA Update Information Organizer (2017‑11‑14 15:22:14)    		PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
    Treeblank.png where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.4.5']]]
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     Constraintif ClinicalDocument.versionNumber > 1
    Treetree.pnghl7:entry
    		1 … *MSource: 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: 6.3.4.6 Diagnostic conclusion section
    Treeblank.png where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]]
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    6.3.4.7 Procedure steps <section> - 1.3.6.1.4.1.19376.1.8.1.2.6

    6.3.4.7.1 Definition and Purpose

    The Procedure steps section contains the description of tissue sampling and dissection: representative specimens and derived specimens dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, electron microscopy, etc.) or biorepository. The only entry for this section is the Specimen Procedure Steps Entry module.

    6.3.4.7.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.2.6Effective Date valid from 2014‑05‑13 19:33:12
    StatusKyellow.png DraftVersion Label2.0
    NameProcedureStepsSectionDisplay NameProcedure Steps Section
    Description
    The Procedure steps section contains the description of tissue dissection: representative specimens and derived specimens dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, electron microscopy, etc.) or biorepository.
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.6
    LabelPaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps 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
    1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
    RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
    Example
    Example
    <section classCode="DOCSECT" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.8.1.2.6"/>  <code code="46059-2" codeSystem="2.16.840.1.113883.6.1" displayName="Special treatments and procedures section"/>  <title>PROCEDURE STEPS 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" contextConductionInd="false">
        <!-- template 1.3.6.1.4.1.19376.1.3.10.4.1 'Specimen Procedure Step' (2016-07-08T13:20:59) -->
      </entry>    </section>
    ItemDTCardConfDescriptionLabel
    hl7:section
    		0 … 1RPaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section
    Treetree.png@classCode
    		cs0 … 1FDOCSECT
    Treetree.png@moodCode
    		cs0 … 1FEVN
     Constraint

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

    @code ="46059-2"

    @codeSystem ="2.16.840.1.113883.6.1"

    @displayName ="Special treatments and procedures section" 

    This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.

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

    The section SHOULD contain as many Specimen Procedure Steps entry elements as there are procedure steps or groups thereof to be described. These entries provide the machine-readable data corresponding to the narrative block. 

    Treetree.pnghl7:templateId
    		II1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.6
    Treetree.pnghl7:code
    		CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section
    Treeblank.pngTreetree.png@code
    		CONF1 … 1F46059-2
    Treeblank.pngTreetree.png@codeSystem
    		1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
    Treeblank.pngTreetree.png@codeSystemName
    		1 … 1FLOINC
    Treeblank.pngTreetree.png@displayName
    		1 … 1FSpecial treatments and procedures section
    Treetree.pnghl7:title
    		ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section
     CONF
    element content shall be "PROCEDURE STEPS SECTION"
    Treetree.pnghl7:text
    		SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section
     Example
    example for use case#1
    <text>
       RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE
    BIOPSY)      <br/>  
    PARAFFIN BLOCK NUMBER: A1.:FOUR SECTIONS FOR EACH STAIN:      <br/>  <paragraph ID="A7102400008">RIGHT BREAST FIVE CORES 8-9:00</paragraph>  <paragraph ID="block_A_1">PARAFFIN BLOCK NUMBER: A1</paragraph>  <paragraph ID="slide_A_1_HE">slide from block A1 HE stained</paragraph>  <paragraph ID="slide_A_1_ER">slide from block A1 ER Immunohistochemistry</paragraph>  <paragraph ID="slide_A_1_PR">slide from block A1 PR Immunohistochemistry</paragraph>  <paragraph ID="slide_A_1_EGFR">slide from block A1 EGFR (PharmDX) Immunohistochemistry</paragraph>  <paragraph ID="slide_A_1_HER2">slide from block A1 HER2 Immunohistochemistry</paragraph>  <paragraph ID="slide_A_1_HER2_FISH">slide block from A1 HER2 FISH</paragraph></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


    Treetree.pnghl7:author
    		0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FAUT
     Example
    author is a person
    <author typeCode="AUT" contextControlCode="OP">
      <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
        <!-- ... -->
      </assignedAuthor>    </author>
    Treeblank.pngTreetree.pnghl7:templateId
    		1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
    Treeblank.pngTreetree.pnghl7:time
    		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
    Treeblank.pngTreetree.pnghl7:assignedAuthor
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FASSIGNED
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		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
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
    		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.
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPSN
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FDEV
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		cs0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
    		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.
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
    		CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPART
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
    		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)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    		IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		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 … *RSpecimen procedure steps 

    Source: PaLM Suppl.APSR 2.0‑3:6.2.5.3
    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: 6.3.4.7 Procedure steps section
    Treeblank.png where [@typeCode='COMP'] [hl7:procedure [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.4.1']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1 

    6.3.5 CDA R2 <entry> Content Modules

    6.3.5.1 Common Specification for all APSR Entry Content Modules

    The unique <entry> Content Module available in all the sections except Procedure Steps <section> of the APSR template is the Problem Organizer <entry>.

    The unique <entry> Content Module available in Procedure Steps <section> of the APSR template is Specimen Procedure Step <entry>.

    Each <entry> Content Module carries machine-readable data related to one Problem on one specimen or on a group of specimens observed for this section.

    Each <entry> Content Module is repeatable below its section, so as to support the use cases where a section reports on more than one specimen or more than one group of specimens.

    6.3.5.2 Problem Organizer – 1.3.6.1.4.1.19376.1.8.1.3.6

    6.3.5.2.1 Definition and purpose

    This Content Module is usable as only <entry> within any Section module except Procedure steps <section>.

    The problem organizer groups the battery of observations together with embedded images performed to investigate on a single problem identified on a specimen or group of specimens. If a Problem cannot be addressed specifically the Problem organizer allows also the grouping around one specimen.

    6.3.5.2.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.3.6Effective Date valid from 2015‑08‑13 10:24:55
    StatusKyellow.png DraftVersion Label2.0
    NameProblemOrganizerDisplay NameProblem Organizer
    Description
    Template CDA Organizer (prototype, directly derived from POCD_RM000040 MIF)


    The problem organizer groups the battery of observations performed to investigate on a single problem identified on a specimen or group of specimens. 
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.3.6
    LabelPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    ClassificationCDA Entry Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Used by / Uses
    Used by 0 transactions and 7 templates, Uses 11 templates
    Used by as NameVersion
    1.3.6.1.4.1.19376.1.3.10.3.1ContainmentKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
    1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
    1.3.6.1.4.1.19376.1.8.1.2.1ContainmentKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
    1.3.6.1.4.1.19376.1.8.1.2.2ContainmentKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
    1.3.6.1.4.1.19376.1.8.1.2.3ContainmentKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
    1.3.6.1.4.1.19376.1.8.1.2.4ContainmentKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
    1.3.6.1.4.1.19376.1.8.1.2.5ContainmentKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
    Uses as NameVersion
    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
    1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
    1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
    1.3.6.1.4.1.19376.1.8.1.4.10ContainmentKyellow.png Embedded Image IHE2016‑06‑22 16:08:01
    2.16.840.1.113883.10.12.307ContainmentKgreen.png CDA RegionOfInterest2005‑09‑07
    1.3.6.1.4.1.19376.1.5.3.1.4.2ContainmentKgreen.png IHE Comment Entry (2014)2013‑12‑20
    1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
    1.3.6.1.4.1.19376.1.3.1.6ContainmentKgreen.png Laboratory Observation (2017)2008‑08‑08
    2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA Reference2005‑09‑07
    RelationshipSpecialization: template 2.16.840.1.113883.10.12.305 (2005‑09‑07)
    Example
    generated example
    <organizer classCode="BATTERY" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.8.1.3.6"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">
        <qualifier>
          <name code="116677004" codeSystem="2.16.840.1.113883.6.96" displayName=" Associated topography (attribute)"/>      <value nullFlavor="cs" code="all children of "362981000"" codeSystem="2.16.840.1.113883.6.96" displayName="all values from 91723000 (Anatomical structure)"/>    </qualifier>      </code>      <component typeCode="COMP">
        <observation>
          <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">
            <value code="115597007" displayName="Description of specimen character (procedure)" codeSystem="2.16.840.1.113883.6.96"/>      </code>        </observation>      </component>      <statusCode code="completed"/>  <effectiveTime>
        <low value="20170131165954"/>  </effectiveTime>      <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>      <performer>
        <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->
      </performer>      <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 0..* R -->
      <component typeCode="COMP" contextConductionInd="true">
        <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (2016-06-22T16:08:01) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' (2005-09-07T00:00:00) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.4.2 'IHE Comment Entry' (2013-12-20T00:00:00) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (2014-05-14T17:09:54) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.3.1.6 'Laboratory Observation' (2008-08-08T00:00:00) -->
      </component>      <reference>
        <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
      </reference>    </organizer>
    Example
    example for use case #1, problem: invasive breast cancer
    <organizer classCode="BATTERY" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.8.1.3.6"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_Problem1"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>  <statusCode code="completed"/>  <effectiveTime>
        <low value="201001041605-0500"/>  </effectiveTime>      <!--The problem is expressed by the result of the observation having the same code as organizer/code-->
      <component>
        <observation classCode="OBS" moodCode="EVN">
          <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>      <value code="C50.9" codeSystem="2.16.840.1.113883.6.3" displayName="Malignant neoplasm of breast, unspecified" codeSystemDisplayName="ICD-10"/>    </observation>      </component>      <component typeCode="COMP" contextConductionInd="true">
        <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (2014-05-14T17:09:54) -->
      </component>      <reference>
        <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
      </reference>    </organizer>
    ItemDTCardConfDescriptionLabel
    hl7:organizer
    		0 … *RProblem organizer groups the battery of observations performed to investigate on a single problem identified on a specimen or a group of specimens. PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treetree.png@classCode
    		cs1 … 1FBATTERY
    Treetree.png@moodCode
    		cs1 … 1FEVN
    Treetree.pnghl7:templateId
    		II1 … 1MPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.3.6
    Treetree.pnghl7:id
    		II0 … *RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treetree.pnghl7:code
    		CD (required)0 … 1RProblem

    		PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.pngTreetree.png@code
    		CONF0 … 1F75326-9
    Treeblank.pngTreetree.png@codeSystem
    		0 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
    Treeblank.pngTreetree.png@codeSystemName
    		0 … 1FLOINC
    Treeblank.pngTreetree.png@displayName
    		0 … 1FProblem
    Treetree.pnghl7:component
    		0 … 1RCoding of the Problem reportedPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.pnghl7:observation
    		0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CD (extensible)1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
    		CONF0 … 1F75326-9
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		0 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
    		0 … 1FLOINC
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
    		0 … 1FProblem
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:qualifier
    		CR0 … *ROptional qualifier for separate problems with identical problem type in one specimen, e.g. a urothelial bladder cancer Invasive cancer) and a prostate cancer (invasive cancer) in one cystoprostatectomy specimen. The anatomic structure is able to differentiate.
    		PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
     Example
    Problem in urinary bladder in cystoprostatectomy specimen
    <qualifier>
      <name code="116677004" codeSystem="2.16.840.1.113883.6.96" displayName="Associated topography (attribute)" codeSystemName="SNOMED-CT"/>  <value code="302512001" codeSystem="2.16.840.1.113883.6.96" displayName=" Entire urinary bladder (body structure)" codeSystemName="SNOMED-CT"/></qualifier>
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		CV0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
    		cs1 … 1F116677004
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		oid1 … 1F2.16.840.1.113883.6.96
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
    		st1 … 1F Associated topography (attribute)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:value
    		CD (extensible)0 … *RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
    		CONF0 … 1F<< 91723000
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		0 … 1F2.16.840.1.113883.6.96 (SNOMED Clinical Terms)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
    		0 … 1FSNOMED-CT
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
    		0 … 1Fall values from Anatomical structure
    Treeblank.pngTreeblank.pngTreetree.pnghl7:value
    		CE (extensible)0 … 1RCode of the problem reportedPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
     CONF
    @code shall be "any_code"
    @codeSystem shall be "2.16.840.1.113883.6.3"
    @codeSystemName shall be "any_code"
    @displayName shall be "ICD-10"
    or
    The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.7 Problem Type (2016‑07‑11 09:52:19)
    Treetree.pnghl7:statusCode
    		CS (required)1 … 1MPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
     ConstraintThe status of the organizer is 

    completed  if the battery of observations for this problem has been performed. It is  aborted  in case some of the intended observations could not be achieve and have been aborted, and appear as such below the organizer.


     CONF
    The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 (DYNAMIC)
    Alert.pngError: Cannot find value set "1.3.6.1.4.1.19376.1.3.11.2"
    Treetree.pnghl7:effectiveTime
    		IVL_TS1 … 1MOrganizer time.

    The period of time (possibly reduced to a point in time) during which the information was collected and assembled. 


    		PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treetree.pnghl7:author
    		0 … *CAuthor


    Source: PaLM 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. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.png where [hl7:author [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.2']]]
     ConstraintThe author SHALL be present if it is different from the main author of the report. For instance the author could be the ordering physician contributing to the Clinical Information section, inside a report authored by the pathologist.
    Treetree.pnghl7:informant
    		0 … *RInformant


    The informant is an actor (person and organization) who provided some of the clinical information carried by this organizer.


    Source: PaLM 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. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.6']]
    Treetree.pnghl7:participant
    		0 … *RTranscriptionist, Device, Responsible, Validator



    Source: PaLM 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. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.7']]
     ConstraintparticipationType "ENT", "DEV", "RESP", "AUTHEN"
    Treetree.pnghl7:performer
    		0 … 1CPerforming lab.

    The performing laboratory is present at this level only if this particular problem on this particular specimen was investigated by a (subcontractor) distinct laboratory from the one issuing the consolidated report 

       
       
    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. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
    Included0 … *R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
    Specimen identification outside an AP observation for differentiating or restituting the problem type


    Source: PaLM Suppl. APSR 2.0-3: 6.3.6.9


    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:component
    		0 … *REmbedded image


    This organizer may carry an image focusing on the problem, either directly embedded or encapsulated within a region of interest.



    Contains 1.3.6.1.4.1.19376.1.8.1.4.10 Embedded Image IHE (2016‑06‑22 16:08:01)    		PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.png where [hl7:observationMedia [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.10']]]
    Treeblank.pngTreetree.png@typeCode
    		cs0 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
     Constraint[@classCode="ROIOVL" and moodCode="EVN"]
    Treeblank.pngTreetree.pnghl7:sequenceNumber
    		INT0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.pngTreetree.pnghl7:seperatableInd
    		BL0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treetree.pnghl7:component
    		0 … *RRegion of interest


    This organizer may carry an image focusing on the problem, either directly embedded or encapsulated within a region of interest.

    In the latter case by an entryRelationship @typeCode="SUBJ"




    Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (2005‑09‑07)    		PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.png where [@typeCode='COMP'] [hl7:regionOfInterest [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.307']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
     Constraint[@classCode="ROIOVL" and moodCode="EVN"]
    Treeblank.pngTreetree.pnghl7:sequenceNumber
    		INT0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.pngTreetree.pnghl7:seperatableInd
    		BL0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treetree.pnghl7:component
    		0 … *RGeneral comment on this particular problem 



    Source: PCC TF-2: 6.3.4.6
    Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20)    		PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.png where [@typeCode='COMP'] [hl7:act [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.20.1.40'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.2']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
    Treeblank.pngTreetree.pnghl7:sequenceNumber
    		INT0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.pngTreetree.pnghl7:seperatableInd
    		BL0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treetree.pnghl7:component
    		0 … *RAny kind of AP observation, for complex observations, e.g. for TNM, ICD-O-3, or Assessment scales, the appropriate templates may be used.


    Source: PaLM Suppl. APSR 2.0-3: 6.3.6.7



    Contains 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54)    		PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.png where [@typeCode='COMP'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.9']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
    Treeblank.pngTreetree.pnghl7:sequenceNumber
    		INT0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.pngTreetree.pnghl7:seperatableInd
    		BL0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treetree.pnghl7:component
    		0 … *CLaboratory observation
    Contains 1.3.6.1.4.1.19376.1.3.1.6 Laboratory Observation (2008‑08‑08)    		PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.png where [@typeCode='COMP'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.1.6']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
    Treeblank.pngTreetree.pnghl7:sequenceNumber
    		INT0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treeblank.pngTreetree.pnghl7:seperatableInd
    		BL0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
    Treetree.pnghl7:reference
    		0 … *RReference to an external document, or to external organizers, or to external observations, 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: 6.3.5.2 Problem organizer

    6.3.5.3 Specimen Procedure Step <entry> - 1.3.6.1.4.1.19376.1.3.10.4.1

    6.3.5.3.1 Definition and purpose

    The Specimen Procedure Step <entry> Content Module contains in machine-readable form all the data concerning one specimen or a group of specimens together with its container(s). It is usable within a Procedure Steps <section> Content Module only. This Content Module structures the machine-readable data, which characterize the specimens and the procedures of their collection and processing (identifiers and types, time intervals, performers, target site).
    By referencing the child procedure ID via an entryRelationship the entry is used in an iterative manner for each single step of specimen collection and processing, which results in derived (child) specimen.
    The resulting specimen is the participant in the procedure according to the CDA-RIM (fig. 6.2.5.3.2-1) with the typeCode="PRD", and the role of "SPEC". The specimen ID is the ParticipantRole.ID.
    Additives (e.g. fixatives) MAY be additional participants with the typeCode="CSM".
    Each specimen is put in or on an appropriate container. The container is described through an EntryRelationship to a Supply whose product is the container (see this volume, 6.3.6.4).
    The specimen reception in laboratory may be expressed through another EntryRelationship of typeCode "COMP", introducing the "specimen received" Act.
    In case the procedure step produces a child specimen, the parent specimen is the specimen on which the procedure is performed. Thus the parent specimen is represented by a Specimen participation to the procedure. In this case, Specimen.SpecimenRole.Id is the id of the parent specimen. These parent specimens might be multiple, for instance in the case of TMA.Therefore, cardinalities of Specimen are [0..*]
    Specimen and their containers carry IDs as well as further attributes, which are defined in the HL7 Specimen DAM.

    HL7 DAM Specimen Release 1.


    6.2.6.4.1-1 container 5.jpg

    Figure 6.3.5.3.1-1 CDA-RMIM of the Specimen Procedure Steps <entry>

    According to the CDA RIM in the Content Module further supporting Content Modules for Participant, and Playing Entity are needed, which have the (preliminary) OIDs 1.3.6.1.4.1.19376.1.3.10.9.20, 1.3.6.1.4.1.19376.1.3.10.9.21). The

    The Code systems and Value sets MAY be organized organ-specific.

    6.3.5.3.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.3.10.4.1Effective Date valid from 2016‑07‑08 13:20:59

    There are versions of templates with this id:
    • SpecimenProcedureStep as of 2016‑07‑08 13:20:59
    • SpecimenProcedureStep as of 2014‑07‑29 16:02:02
    StatusKyellow.png DraftVersion Label2.0
    NameSpecimenProcedureStepDisplay NameSpecimen Procedure Step
    Description
    Template CDA Procedure (prototype, directly derived from POCD_RM000040 MIF)
    for Specimen procedure step in APSR2.

    This entry collects all the information of source, method and result of a specimen procedure from the collection out of the patient through the final product of a stained histologic section or cytologic smear on a glass slide, or a WSI of such a slide. It reflects the workflow and the probe tracking of a pathology laboratory.
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.1
    LabelPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
    ClassificationCDA Entry Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Used by / Uses
    Used by 0 transactions and 4 templates, Uses 8 templates
    Used by as NameVersion
    1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
    1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
    1.3.6.1.4.1.19376.1.8.1.2.6Link.pngKyellow.png Procedure Steps Section (2.0)2014‑05‑13 19:33:12
    1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
    Uses as NameVersion
    1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
    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
    1.3.6.1.4.1.19376.1.3.10.9.44ContainmentKyellow.png CDA Participant (Body) Procedure Steps APSR2 (2.0)2014‑10‑26 17:06:28
    1.3.6.1.4.1.19376.1.3.10.9.22ContainmentKyellow.png CDA Supply Container APSR2 (2.0)2016‑07‑29 12:09:33
    1.3.6.1.4.1.19376.1.3.1.3ContainmentKgreen.png Specimen Received (2017)2008‑08‑08
    1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
    2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA Reference2005‑09‑07
    RelationshipAdaptation: template 2.16.840.1.113883.10.12.306 (2005‑09‑07)
    Example
    generated example
    <procedure negationInd="false" classCode="PROC" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.3.10.4.1"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="117617002" displayName="Immunohistochemistry procedure (procedure)" codeSystem="2.16.840.1.113883.5.96">
        <qualifier>
          <name code="246094008 or 246355002" codeSystem="2.16.840.1.113883.6.96" displayName="Component investigated (attribute) or Supporting structure (attribute)"/>      <value code="23307004" codeSystem="2.16.840.1.113883.6.96" displayName="Estrogen receptor (substance)"/>    </qualifier>      </code>      <text/>  <statusCode code="completed"/>  <effectiveTime>
        <low value="20161110104817"/>  </effectiveTime>      <targetSiteCode code="441652008" codeSystem="2.16.840.1.113883.6.96" displayName="Formalin-fixed paraffin-embedded tissue specimen (specimen)"/>  <specimen typeCode="SPC">
        <specimenRole classCode="SPEC">
          <id/>    </specimenRole>      </specimen>      <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>      <participant>
        <!-- template 1.3.6.1.4.1.19376.1.3.10.9.44 'CDA Participant (Body) Procedure Steps APSR2' (2014-10-26T17:06:28) -->
      </participant>      <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">
        <seperatableInd value="false"/>    <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.22 'CDA Supply Container APSR2' (2016-07-29T12:09:33) -->
      </entryRelationship>      <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">
        <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.3.1.3 'Specimen Received' (2008-08-08T00:00:00) -->
      </entryRelationship>      <entryRelationship negationInd="false" typeCode="REFR" inversionInd="false" contextConductionInd="true">
        <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.4.1 'Specimen Procedure Step' (2016-07-08T13:20:59) -->
      </entryRelationship>      <reference>
        <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
      </reference>    </procedure>
    ItemDTCardConfDescriptionLabel
    hl7:procedure
    		0 … *RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
    Treetree.png@classCode
    		cs1 … 1FPROC
    Treetree.png@moodCode
    		cs1 … 1FEVN
    Treetree.pnghl7:templateId
    		II1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.3.10.4.1
    Treetree.pnghl7:id
    		II0 … *RProcedure 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
    Treetree.pnghl7:code
    		CD (extensible)1 … 1MCoded procedurePaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
     Constraintfor 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)"/>
    Treeblank.pngTreetree.pnghl7:qualifier
    		CR (extensible)0 … *CQualifier 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
     ConstraintUsed 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>
    Treeblank.pngTreeblank.pngTreetree.pnghl7:name
    		CV (extensible)1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
    		cs0 … 1F246094008_or_246355002
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		oid0 … 1F2.16.840.1.113883.6.96
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
    		st0 … 1FComponent investigated (attribute) or Supporting structure (attribute)
    Treeblank.pngTreeblank.pngTreetree.pnghl7:value
    		CD (extensible)1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
    		cs1 … 1R
     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)"
    Treetree.pnghl7:text
    		ED0 … 1RPaLM 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>
    Treetree.pnghl7:statusCode
    		CS (required)0 … 1RPaLM 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)
    Treetree.pnghl7:effectiveTime
    		IVL_TS0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
    Treetree.pnghl7:approachSiteCode
    		CD (extensible)0 … 1RApproach site in specimen collectionPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
    Treeblank.pngTreetree.png@code
    		CONF0 … 1Fany_code
    Treeblank.pngTreetree.png@codeSystem
    		0 … 1F2.16.840.1.113883.5.1052 (Act Site)
    Treeblank.pngTreetree.png@codeSystemName
    		0 … 1Fany_code
    Treeblank.pngTreetree.png@displayName
    		0 … 1FActSite
    Treetree.pnghl7:target​Site​Code
    		CD (extensible)0 … 1RTarget site in body or relative parent relationship in case of  specimen processingPaLM 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"/>
    Treeblank.pngTreetree.pnghl7:qualifier
    		CR (extensible)0 … *Coptional qualifiers for specifying body structures or / and lateralityPaLM 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>
    Treeblank.pngTreeblank.pngTreetree.pnghl7:name
    		CV (extensible)1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
    		st0 … 1FSpecimen source topography
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		oid1 … 1F2.16.840.1.113883.6.96
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
    		cs1 … 1F118169006
    Treeblank.pngTreeblank.pngTreetree.pnghl7:value
    		CD (extensible)0 … *RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
    		CONF0 … 1 @code shall be out of choice:
    • <<272099008
    • Descriptor (qualifier value)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		0 … 1F2.16.840.1.113883.6.96 (SNOMED Clinical Terms)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
    		0 … 1FSCT
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
    		0 … 1Fall children of "Descriptor, qualifier values", e.g. right lower quadrantt
    Treetree.pnghl7:methodCode
    		CD (extensible)0 … *RIdentifies the technique used to perform a procedure
    		PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
    Treeblank.pngTreetree.png@codeSystem
    		cs1 … 1F2.16.840.1.113883.5.1065
    Included0 … 1R 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>
    Treetree.pnghl7:specimen
    		0 … 1RRequired 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:performer
    		0 … 1RContains 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
    Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
    Treetree.pnghl7:author
    		0 … *CContains 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
    Treeblank.png where [hl7:author [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.2']]]
    Treetree.pnghl7:participant
    		1 … *MOne 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
    Treeblank.png where [not(@nullFlavor)]
    Treetree.pnghl7:entryRelationship
    		0 … *RArtificial 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
    Treeblank.png where [@typeCode='COMP'] [hl7:supply [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.22']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
     Constraintfor manufactured product


    classCode = MANU

    for DrugOrOtherMaterial
    classCode = MMAT
    code from MaterialEntityClassType


    Treetree.pnghl7:entryRelationship
    		0 … 1RSpecimen 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
    Treeblank.png where [@typeCode='COMP'] [hl7:act [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.1.3']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
    Treetree.pnghl7:entryRelationship
    		0 … *RReferencing 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
    Treeblank.png where [@typeCode='REFR'] [hl7:procedure [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.4.1']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FREFR
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
     Constraintcontains only ID of the child procedure, which is fully described in a dedicated entry further down in the Procedure step section.
    Treetree.pnghl7:reference
    		0 … *RReference 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

    6.3.6 CDA R2 Child Element Content Modules

    This section specifies the Content Modules designed for child elements. A child element is a child of the CDA header or a child of a <section>, or an element nested at various depths below an <entry>, or an element appearing at some combination of these locations.

    6.3.6.1 Specimen Collector in Header – 1.3.6.1.4.1.19376.1.8.1.4.1

    6.3.6.1.1 Definition and purpose

    This Content Module is usable only in the CDA header.

    This Content Module is used only in the situation where the specimen was not collected by the ordering physician. (See use cases in volume 1)

    6.3.6.1.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.4.1Effective Date valid from 2016‑06‑13 14:21:13
    StatusKyellow.png DraftVersion Label
    NameCDAParticipantSpecimenCollectorDisplay NameCDA Participant Specimen Collector
    Description
    Template CDA participant (prototype, directly derived from POCD_RM000040 MIF)


    This Content Module is usable only in the CDA header. 

    This Content Module is used only in the situation where the specimen was not collected by the ordering physician.


    LabelPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    ClassificationCDA Header 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
    1.3.6.1.4.1.19376.1.8.1.1.1IncludeKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
    Uses as NameVersion
    2.16.840.1.113883.10.12.152ContainmentKgreen.png CDA Person2005‑09‑07
    2.16.840.1.113883.10.12.151ContainmentKgreen.png CDA Organization2005‑09‑07
    RelationshipSpecialization: template 2.16.840.1.113883.10.12.108 (2005‑09‑07)
    Example
    generated example
    <participant typeCode="DIST" contextControlCode="OP">
      <templateID root="1.3.6.1.4.1.19376.1.8.1.4.1"/>  <time>
        <low value="20170127121035"/>  </time>      <associatedEntity classCode="PROV">
        <id root="1.2.3.999" extension="--example only--"/>    <code code="--code--" codeSystem="2.16.840.1.113883.5.111"/>    <addr>addr</addr>    <telecom/>    <associatedPerson>
          <!-- template 2.16.840.1.113883.10.12.152 'CDA Person' (dynamic) -->
        </associatedPerson>        <scopingOrganization>
          <!-- template 2.16.840.1.113883.10.12.151 'CDA Organization' (dynamic) -->
        </scopingOrganization>      </associatedEntity>    </participant>
    ItemDTCardConfDescriptionLabel
    hl7:participant
    		0 … *RThe Specimen Collector Content Module is only used in case a specimen provided as input to the AP act documented in this report, was collected by a different party than the ordering physician. In that case, this specimen collector is represented in the CDA header as a participant element with the typeCode attribute valued “DIST” and the sub-element participant/time carries the time period of the specimen collection.
    		PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treetree.png@typeCode
    		cs1 … 1FDIST
    Treetree.pnghl7:templateID
    		II1 … 1MPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.1
    Treetree.pnghl7:time
    		IVL_TS1 … 1MSpecimen collection time


    The specimen collection time is an interval, which may be reduced to a point in time (see usage of data type IVL_TS).
    		PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treetree.pnghl7:associated​Entity
    		0 … 1RAt least one of the two elements

    associatedPerson and scopingOrganization must be present. Both may be present.  
    		PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreetree.png@classCode
    		cs1 … 1FPROV
    Treeblank.pngTreetree.pnghl7:id
    		II1 … *RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreetree.pnghl7:addr
    		AD1 … *RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreetree.pnghl7:telecom
    		TEL.AT1 … *RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreetree.pnghl7:associated​Person
    		0 … *CPerson who collected the specimen.
    Only full name(s) SHALL be given.
    Contains 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)    		PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreetree.pnghl7:scoping​Organization
    		0 … 1COrganization taking care for specimen collection.
    Identifiers, name, telecom, and address SHOULD be given.
    Contains 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)    		PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

    6.3.6.2 Author – 1.3.6.1.4.1.19376.1.8.1.4.2

    6.3.6.2.1 Definition and purpose

    This Content Module is usable in the CDA header, in a <section> and at various depths of an <entry>.

    It describes an author having contributed to the document wholly or to a portion of it (e.g., a section, an observation, a group of observations).

    A given document or any delimited portion of it may have more than one author.

    An author MAY be a person or a device (manufactured device or software system). In both cases the scoping organization MAY be described.

    6.3.6.2.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.4.2Effective Date valid from 2016‑06‑21 14:02:11
    StatusKyellow.png DraftVersion Label
    NameCDAAuthorIHEDisplay NameCDA author IHE
    Description
    Template CDA author (prototype, directly derived from POCD_RM000040 MIF).
       
   
    This Content Module is usable in the CDA header, in a <section> and at various depths of an <entry>.

    It describes an author having contributed to the document wholly or to a portion of it (e.g., a section, an observation, a group of observations).
     

       
    A given document or any delimited portion of it may have more than one author.

    An author MAY be a person or a device (manufactured device or software system). In both cases the scoping organization MAY be described.
    LabelPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    ClassificationCDA Header Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Used by / Uses
    Used by 0 transactions and 34 templates, Uses 2 templates
    Used by as NameVersion
    1.3.6.1.4.1.19376.1.3.10.3.1IncludeKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
    1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
    1.3.6.1.4.1.19376.1.8.1.2.1IncludeKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
    1.3.6.1.4.1.19376.1.8.1.2.2IncludeKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
    1.3.6.1.4.1.19376.1.8.1.2.3IncludeKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
    1.3.6.1.4.1.19376.1.8.1.2.4IncludeKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
    1.3.6.1.4.1.19376.1.8.1.2.5IncludeKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
    1.3.6.1.4.1.19376.1.8.1.2.6IncludeKyellow.png Procedure Steps Section (2.0)2014‑05‑13 19:33:12
    1.3.6.1.4.1.19376.1.8.1.2.7IncludeKcancelledblue.png Report Textual Summary Section (2.0)2016‑06‑13 17:54:42
    1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
    1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
    1.3.6.1.4.1.19376.1.3.10.4.2ContainmentKyellow.png TNM Stage Observation (2.0)2014‑05‑13 15:45:13
    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
    1.3.6.1.4.1.19376.1.3.10.4.4ContainmentKyellow.png Assessment Scales Observation for Scoring Systems APSR2 (2.0)2016‑10‑06 13:12:00
    1.3.6.1.4.1.19376.1.3.10.4.5ContainmentKyellow.png CDA Update Information Organizer (2.0)2017‑11‑14 15:22:14
    1.3.6.1.4.1.19376.1.3.10.9.22ContainmentKyellow.png CDA Supply Container APSR2 (2.0)2016‑07‑29 12:09:33
    1.3.6.1.4.1.19376.1.3.10.9.25ContainmentKyellow.png TNM T-Observation (2.0)2014‑12‑02 15:54:17
    1.3.6.1.4.1.19376.1.3.10.9.26ContainmentKyellow.png TNM N-Observation (2.0)2014‑12‑02 16:34:50
    1.3.6.1.4.1.19376.1.3.10.9.27ContainmentKyellow.png TNM M-Observation (2.0)2014‑12‑02 16:32:30
    1.3.6.1.4.1.19376.1.3.10.9.28ContainmentKyellow.png TNM Grading (2.0)2015‑11‑15 13:01:18
    1.3.6.1.4.1.19376.1.3.10.9.29ContainmentKyellow.png TNM R-status (2.0)2015‑06‑30 13:38:30
    1.3.6.1.4.1.19376.1.3.10.9.30ContainmentKyellow.png TNM a (2.0)2015‑06‑22 15:13:46
    1.3.6.1.4.1.19376.1.3.10.9.31ContainmentKyellow.png TNM r (2.0)2015‑06‑22 17:38:42
    1.3.6.1.4.1.19376.1.3.10.9.32ContainmentKyellow.png TNM y (2.0)2015‑06‑22 17:28:17
    1.3.6.1.4.1.19376.1.3.10.9.33ContainmentKyellow.png TNM Serum tumor markers (2.0)2015‑11‑06 14:28:44
    1.3.6.1.4.1.19376.1.3.10.9.34ContainmentKyellow.png TNM Lymphatic Invasion (2.0)2015‑11‑16 14:01:58
    1.3.6.1.4.1.19376.1.3.10.9.35ContainmentKyellow.png TNM Venous Invasion (2.0)2015‑11‑16 13:40:28
    1.3.6.1.4.1.19376.1.3.10.9.36ContainmentKyellow.png TNM Perineural Invasion (2.0)2015‑11‑11 16:13:40
    1.3.6.1.4.1.19376.1.3.10.9.37ContainmentKyellow.png TNM Number of nodes (2.0)2014‑12‑02 16:48:36
    1.3.6.1.4.1.19376.1.3.10.9.43ContainmentKyellow.png Assessment Scoring Item APSR 2.0 (2.0)2016‑10‑11 10:26:17
    1.3.6.1.4.1.19376.1.3.10.9.42Link.pngKyellow.png Assessment Scoring System APSR 2.0 (2.0)2016‑10‑10 11:33:36
    1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
    1.3.6.1.4.1.19376.1.8.1.4.10ContainmentKyellow.png Embedded Image IHE2016‑06‑22 16:08:01
    1.3.6.1.4.1.19376.1.8.1.4.9Link.pngKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
    Uses as NameVersion
    2.16.840.1.113883.10.12.152IncludeKgreen.png CDA Person2005‑09‑07
    2.16.840.1.113883.10.12.151IncludeKgreen.png CDA Organization2005‑09‑07
    RelationshipAdaptation: template 2.16.840.1.113883.10.12.102 (DYNAMIC)
    Example
    author is a person
    <author typeCode="AUT">
      <functionCode code="DISPHYS" displayName="discharging physician" codeSystem="2.16.840.1.113883.5.88" codeSystemName="ParticipationFunction"/>  <time value="20130407130000+0500"/>  <assignedAuthor classCode="ASSIGNED">
        <assignedPerson classCode="PSN" determinerCode="INSTANCE">
          <name>
            <given>Marie</given>        <family>Müller</family>      </name>        </assignedPerson>        <representedOrganization>
          <id root="2.16.840.1.113883.19.5"/>      <name>Beispiel Krankenhaus</name>    </representedOrganization>      </assignedAuthor>    </author>
    Example
    author is a device
    <author typeCode="AUT">
      <assignedAuthor classCode="ASSIGNED">
        <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
          <code>...</code>    </assignedAuthoringDevice>      </assignedAuthor>    </author>
    ItemDTCardConfDescriptionLabel
    hl7:author
    		0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treetree.png@typeCode
    		cs1 … 1FAUT
     Example
    author is a person
    <author typeCode="AUT" contextControlCode="OP">
      <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
        <!-- ... -->
      </assignedAuthor>    </author>
    Treetree.pnghl7:templateId
    		1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
    Treetree.pnghl7:time
    		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
    Treetree.pnghl7:assignedAuthor
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.png@classCode
    		cs0 … 1FASSIGNED
    Treeblank.pngTreetree.pnghl7:id
    		II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.pnghl7:addr
    		AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.pnghl7:telecom
    		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
    Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
    		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.
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPSN
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FDEV
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		cs0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.pnghl7:represented​Organization
    		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.
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
    		CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPART
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
    		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)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    		IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
    		CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

    6.3.6.3 Content Validator – 1.3.6.1.4.1.19376.1.8.1.4.3

    6.3.6.3.1 Definition and purpose

    This Content Module is usable only in the CDA header.

    It describes a pathologist having verified the content of the report, using the element authenticator. This element authenticator is used when the pathologist having verified the content of the report is distinct from the pathologist assuming the legal responsibility for this report, described in the legalAuthenticator element.

    The report MAY have zero or more Content Validators.

    6.3.6.3.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.4.2Effective Date valid from 2016‑06‑21 14:02:11
    StatusKyellow.png DraftVersion Label
    NameCDAAuthorIHEDisplay NameCDA author IHE
    Description
    Template CDA author (prototype, directly derived from POCD_RM000040 MIF).
       
   
    This Content Module is usable in the CDA header, in a <section> and at various depths of an <entry>.

    It describes an author having contributed to the document wholly or to a portion of it (e.g., a section, an observation, a group of observations).
     

       
    A given document or any delimited portion of it may have more than one author.

    An author MAY be a person or a device (manufactured device or software system). In both cases the scoping organization MAY be described.
    LabelPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    ClassificationCDA Header Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Used by / Uses
    Used by 0 transactions and 34 templates, Uses 2 templates
    Used by as NameVersion
    1.3.6.1.4.1.19376.1.3.10.3.1IncludeKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
    1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
    1.3.6.1.4.1.19376.1.8.1.2.1IncludeKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
    1.3.6.1.4.1.19376.1.8.1.2.2IncludeKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
    1.3.6.1.4.1.19376.1.8.1.2.3IncludeKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
    1.3.6.1.4.1.19376.1.8.1.2.4IncludeKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
    1.3.6.1.4.1.19376.1.8.1.2.5IncludeKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
    1.3.6.1.4.1.19376.1.8.1.2.6IncludeKyellow.png Procedure Steps Section (2.0)2014‑05‑13 19:33:12
    1.3.6.1.4.1.19376.1.8.1.2.7IncludeKcancelledblue.png Report Textual Summary Section (2.0)2016‑06‑13 17:54:42
    1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
    1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
    1.3.6.1.4.1.19376.1.3.10.4.2ContainmentKyellow.png TNM Stage Observation (2.0)2014‑05‑13 15:45:13
    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
    1.3.6.1.4.1.19376.1.3.10.4.4ContainmentKyellow.png Assessment Scales Observation for Scoring Systems APSR2 (2.0)2016‑10‑06 13:12:00
    1.3.6.1.4.1.19376.1.3.10.4.5ContainmentKyellow.png CDA Update Information Organizer (2.0)2017‑11‑14 15:22:14
    1.3.6.1.4.1.19376.1.3.10.9.22ContainmentKyellow.png CDA Supply Container APSR2 (2.0)2016‑07‑29 12:09:33
    1.3.6.1.4.1.19376.1.3.10.9.25ContainmentKyellow.png TNM T-Observation (2.0)2014‑12‑02 15:54:17
    1.3.6.1.4.1.19376.1.3.10.9.26ContainmentKyellow.png TNM N-Observation (2.0)2014‑12‑02 16:34:50
    1.3.6.1.4.1.19376.1.3.10.9.27ContainmentKyellow.png TNM M-Observation (2.0)2014‑12‑02 16:32:30
    1.3.6.1.4.1.19376.1.3.10.9.28ContainmentKyellow.png TNM Grading (2.0)2015‑11‑15 13:01:18
    1.3.6.1.4.1.19376.1.3.10.9.29ContainmentKyellow.png TNM R-status (2.0)2015‑06‑30 13:38:30
    1.3.6.1.4.1.19376.1.3.10.9.30ContainmentKyellow.png TNM a (2.0)2015‑06‑22 15:13:46
    1.3.6.1.4.1.19376.1.3.10.9.31ContainmentKyellow.png TNM r (2.0)2015‑06‑22 17:38:42
    1.3.6.1.4.1.19376.1.3.10.9.32ContainmentKyellow.png TNM y (2.0)2015‑06‑22 17:28:17
    1.3.6.1.4.1.19376.1.3.10.9.33ContainmentKyellow.png TNM Serum tumor markers (2.0)2015‑11‑06 14:28:44
    1.3.6.1.4.1.19376.1.3.10.9.34ContainmentKyellow.png TNM Lymphatic Invasion (2.0)2015‑11‑16 14:01:58
    1.3.6.1.4.1.19376.1.3.10.9.35ContainmentKyellow.png TNM Venous Invasion (2.0)2015‑11‑16 13:40:28
    1.3.6.1.4.1.19376.1.3.10.9.36ContainmentKyellow.png TNM Perineural Invasion (2.0)2015‑11‑11 16:13:40
    1.3.6.1.4.1.19376.1.3.10.9.37ContainmentKyellow.png TNM Number of nodes (2.0)2014‑12‑02 16:48:36
    1.3.6.1.4.1.19376.1.3.10.9.43ContainmentKyellow.png Assessment Scoring Item APSR 2.0 (2.0)2016‑10‑11 10:26:17
    1.3.6.1.4.1.19376.1.3.10.9.42Link.pngKyellow.png Assessment Scoring System APSR 2.0 (2.0)2016‑10‑10 11:33:36
    1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
    1.3.6.1.4.1.19376.1.8.1.4.10ContainmentKyellow.png Embedded Image IHE2016‑06‑22 16:08:01
    1.3.6.1.4.1.19376.1.8.1.4.9Link.pngKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
    Uses as NameVersion
    2.16.840.1.113883.10.12.152IncludeKgreen.png CDA Person2005‑09‑07
    2.16.840.1.113883.10.12.151IncludeKgreen.png CDA Organization2005‑09‑07
    RelationshipAdaptation: template 2.16.840.1.113883.10.12.102 (DYNAMIC)
    Example
    author is a person
    <author typeCode="AUT">
      <functionCode code="DISPHYS" displayName="discharging physician" codeSystem="2.16.840.1.113883.5.88" codeSystemName="ParticipationFunction"/>  <time value="20130407130000+0500"/>  <assignedAuthor classCode="ASSIGNED">
        <assignedPerson classCode="PSN" determinerCode="INSTANCE">
          <name>
            <given>Marie</given>        <family>Müller</family>      </name>        </assignedPerson>        <representedOrganization>
          <id root="2.16.840.1.113883.19.5"/>      <name>Beispiel Krankenhaus</name>    </representedOrganization>      </assignedAuthor>    </author>
    Example
    author is a device
    <author typeCode="AUT">
      <assignedAuthor classCode="ASSIGNED">
        <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
          <code>...</code>    </assignedAuthoringDevice>      </assignedAuthor>    </author>
    ItemDTCardConfDescriptionLabel
    hl7:author
    		0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treetree.png@typeCode
    		cs1 … 1FAUT
     Example
    author is a person
    <author typeCode="AUT" contextControlCode="OP">
      <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
        <!-- ... -->
      </assignedAuthor>    </author>
    Treetree.pnghl7:templateId
    		1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
    Treetree.pnghl7:time
    		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
    Treetree.pnghl7:assignedAuthor
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.png@classCode
    		cs0 … 1FASSIGNED
    Treeblank.pngTreetree.pnghl7:id
    		II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.pnghl7:addr
    		AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.pnghl7:telecom
    		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
    Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
    		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.
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPSN
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FDEV
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		cs0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.pnghl7:represented​Organization
    		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.
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
    		CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPART
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
    		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)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    		IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
    		CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

    6.3.6.4 Specimen Container in Specimen Procedure Step - 1.3.6.1.4.1.19376.1.3.10.9.22

    6.3.6.4.1 Definition and purpose

    This Supporting Content Module is usable in the Specimen Procedure Steps <entry> (see 6.2.6.4). It describes the properties of containers, in or on which the specimens are processed. The relations between container and specimen are described in the HL7 Specimen DAM.

    HL7 DAM Specimen Release 1.

    For Anatomic Pathology the CDA Content Modules "Material" and "ManufacturedMaterial" were modified under the (preliminary) OIDs 1.3.6.1.4.1.19376.1.3.10.9.23 and 1.3.6.1.4.1.19376.1.3.10.9.24

    6.3.6.4.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.3.10.9.22Effective Date valid from 2016‑07‑29 12:09:33
    StatusKyellow.png DraftVersion Label2.0
    NameCDASupplyContainerAPSR2Display NameCDA Supply Container APSR2
    Description
    Template CDA Supply (prototype, directly derived from POCD_RM000040 MIF)

    This entry describes the properties of a container (and its components) which holds a specimen. It is usable within a Specimen Procedure Step entry and is repeatable in one procedure step for describing container components, too (e.g. container plus embedding medium, or microscopic slide plus mounting medium plus coverslip)
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.22
    LabelPaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
    ClassificationCDA Entry Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Used by / Uses
    Used by 0 transactions and 4 templates, Uses 6 templates
    Used by as NameVersion
    1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
    1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
    1.3.6.1.4.1.19376.1.8.1.2.6Link.pngKyellow.png Procedure Steps Section (2.0)2014‑05‑13 19:33:12
    1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
    Uses as NameVersion
    1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
    1.3.6.1.4.1.19376.1.3.10.9.24ContainmentKyellow.png CDA ManufacturedProduct APSR22016‑09‑09 12:37:49
    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
    2.16.840.1.113883.10.12.300ContainmentKgreen.png CDA Clinical Statement2005‑09‑07
    RelationshipSpecialization: template 2.16.840.1.113883.10.12.309 (2005‑09‑07)
    Example
    example for use case #1, grossing and embedding
    <supply classCode="SPLY" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.3.10.9.22"/>  <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_block_A_1-C"/>  <code code="74384-9" codeSystem="2.16.840.1.113883.6.1" displayName="Specimen container"/>  <text/>  <statusCode code="completed"/>  <effectiveTime/>  <priorityCode/>  <repeatNumber/>  <independentInd value="false"/>  <quantity value="1"/>  <expectedUseTime>
        <low value="201001030905-0500"/>  </expectedUseTime>      <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 0..* O
    ID of the specimen linked to the container -->
      <specimen typeCode="SPC">
        <specimenRole classCode="SPEC">
          <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_block_A_1"/>    </specimenRole>      </specimen>      <product typeCode="PRD">
        <!-- template 1.3.6.1.4.1.19376.1.3.10.9.24 'CDA ManufacturedProduct APSR2' (2016-09-09T12:37:49) -->
      </product>      <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>      <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">
        <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 2.16.840.1.113883.10.12.300 'CDA Clinical Statement' (2005-09-07T00:00:00) -->
      </entryRelationship>    </supply>
    ItemDTCardConfDescriptionLabel
    hl7:supply
    		0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
    Treetree.png@classCode
    		cs1 … 1FSPLY
    Treetree.png@moodCode
    		cs1 … 1FEVN
    Treetree.pnghl7:templateId
    		II1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.3.10.9.22
    Treetree.pnghl7:id
    		II0 … *RContainer ID, coming from the LIS
    		PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
    Treetree.pnghl7:code
    		CD0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
    Treeblank.pngTreetree.png@code
    		CONF0 … 1F74384-9
    Treeblank.pngTreetree.png@codeSystem
    		0 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
    Treeblank.pngTreetree.png@codeSystemName
    		0 … 1FLOINC
    Treeblank.pngTreetree.png@displayName
    		0 … 1FSpecimen container
    Treetree.pnghl7:text
    		ED0 … 1RTextual description of the container (plus container components)PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
     Example
    plastic tube
    <text>plastic tube</text>
     Example
    Block
    <text>paraffin block</text>
     Example
    Slide
    <text>slide with mounting medium and coverslip</text>
    Treetree.pnghl7:statusCode
    		CS (required)1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
     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
    		SXCM_TS0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
    Treetree.pnghl7:quantity
    		PQ0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
    Treetree.pnghl7:expectedUseTime
    		IVL_TS0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
    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:product
    		1 … 1MContains 1.3.6.1.4.1.19376.1.3.10.9.24 CDA ManufacturedProduct APSR2 (2016‑09‑09 12:37:49)PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
    Treeblank.png where [@typeCode='PRD'] [not(@nullFlavor)]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FPRD
    Treetree.pnghl7:performer
    		0 … *CContains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
    Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
    Treetree.pnghl7:author
    		0 … *CContains 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: 6.3.6.4 Specimen container
    Treeblank.png where [hl7:author [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.2']]]
    Treetree.pnghl7:informant
    		0 … *RContains 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: 6.3.6.4 Specimen container
    Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.6']]
    Treetree.pnghl7:entryRelationship
    		0 … *RContains 2.16.840.1.113883.10.12.300 CDA Clinical Statement (2005‑09‑07)PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
    Treeblank.png where [@typeCode='COMP'] [hl7:act [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.301']] or
    [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.302']] or
    [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.303']] or
    [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.304']] or
    [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.305']] or
    [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.306']] or
    [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.307']] or
    [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.308']] or
    [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.309']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
    Treeblank.pngTreetree.png@inversionInd
    		bl0 … 1 
    Treeblank.pngTreetree.png@negationInd
    		bl0 … 1 
    Treeblank.pngTreetree.pnghl7:sequenceNumber
    		INT0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
    Treeblank.pngTreetree.pnghl7:seperatableInd
    		BL0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

    6.3.6.5 Informant – 1.3.6.1.4.1.19376.1.8.1.4.6

    6.3.6.5.1 Definition and purpose

    This Content Module is usable in the CDA header, in a <section> and within an <entry>.

    It describes a person having provided some piece of relevant information for the document.

    A <ClinicalDocument> or a <section> or any kind of act below an <entry>, MAY have zero or more informant.

    6.3.6.5.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.4.6Effective Date valid from 2016‑07‑08 11:22:58
    StatusKyellow.png DraftVersion Label2.0
    NameCDAinformantHeaderBodyAPSR2Display NameCDA Informant(Header&Body) APSR2
    Description
    Template CDA Informant Body (prototype, directly derived from POCD_RM000040 MIF)

       
    An informant is either an assignedEntity (a professional participating to the healthcare process, and who was assigned a defined role in that process) or a relatedEntity (a person who knows the patient and has provided relevant information concerning the patient). Hence the condition is either assignedEntity is present or relatedEntity is present. 
    ContextSibling nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.4.6
    LabelPaLM Suppl. APSR 2.0‑3: 6.3.6.5 Informant
    ClassificationTemplate type not specified
    Open/ClosedOpen (other than defined elements are allowed)
    Used by / Uses
    Used by 0 transactions and 32 templates, Uses 2 templates
    Used by as NameVersion
    1.3.6.1.4.1.19376.1.3.10.4.2ContainmentKyellow.png TNM Stage Observation (2.0)2014‑05‑13 15:45:13
    1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
    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
    1.3.6.1.4.1.19376.1.3.10.4.4ContainmentKyellow.png Assessment Scales Observation for Scoring Systems APSR2 (2.0)2016‑10‑06 13:12:00
    1.3.6.1.4.1.19376.1.3.10.9.22ContainmentKyellow.png CDA Supply Container APSR2 (2.0)2016‑07‑29 12:09:33
    1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
    1.3.6.1.4.1.19376.1.8.1.2.6Link.pngKyellow.png Procedure Steps Section (2.0)2014‑05‑13 19:33:12
    1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
    1.3.6.1.4.1.19376.1.3.10.9.25ContainmentKyellow.png TNM T-Observation (2.0)2014‑12‑02 15:54:17
    1.3.6.1.4.1.19376.1.3.10.9.26ContainmentKyellow.png TNM N-Observation (2.0)2014‑12‑02 16:34:50
    1.3.6.1.4.1.19376.1.3.10.9.27ContainmentKyellow.png TNM M-Observation (2.0)2014‑12‑02 16:32:30
    1.3.6.1.4.1.19376.1.3.10.9.28ContainmentKyellow.png TNM Grading (2.0)2015‑11‑15 13:01:18
    1.3.6.1.4.1.19376.1.3.10.9.29ContainmentKyellow.png TNM R-status (2.0)2015‑06‑30 13:38:30
    1.3.6.1.4.1.19376.1.3.10.9.30ContainmentKyellow.png TNM a (2.0)2015‑06‑22 15:13:46
    1.3.6.1.4.1.19376.1.3.10.9.31ContainmentKyellow.png TNM r (2.0)2015‑06‑22 17:38:42
    1.3.6.1.4.1.19376.1.3.10.9.32ContainmentKyellow.png TNM y (2.0)2015‑06‑22 17:28:17
    1.3.6.1.4.1.19376.1.3.10.9.33ContainmentKyellow.png TNM Serum tumor markers (2.0)2015‑11‑06 14:28:44
    1.3.6.1.4.1.19376.1.3.10.9.34ContainmentKyellow.png TNM Lymphatic Invasion (2.0)2015‑11‑16 14:01:58
    1.3.6.1.4.1.19376.1.3.10.9.35ContainmentKyellow.png TNM Venous Invasion (2.0)2015‑11‑16 13:40:28
    1.3.6.1.4.1.19376.1.3.10.9.36ContainmentKyellow.png TNM Perineural Invasion (2.0)2015‑11‑11 16:13:40
    1.3.6.1.4.1.19376.1.3.10.9.37ContainmentKyellow.png TNM Number of nodes (2.0)2014‑12‑02 16:48:36
    1.3.6.1.4.1.19376.1.3.10.9.43ContainmentKyellow.png Assessment Scoring Item APSR 2.0 (2.0)2016‑10‑11 10:26:17
    1.3.6.1.4.1.19376.1.3.10.9.42Link.pngKyellow.png Assessment Scoring System APSR 2.0 (2.0)2016‑10‑10 11:33:36
    1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
    1.3.6.1.4.1.19376.1.3.10.3.1Link.pngKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
    1.3.6.1.4.1.19376.1.8.1.2.1Link.pngKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
    1.3.6.1.4.1.19376.1.8.1.2.2Link.pngKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
    1.3.6.1.4.1.19376.1.8.1.2.3Link.pngKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
    1.3.6.1.4.1.19376.1.8.1.2.4Link.pngKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
    1.3.6.1.4.1.19376.1.8.1.2.5Link.pngKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
    1.3.6.1.4.1.19376.1.8.1.4.10ContainmentKyellow.png Embedded Image IHE2016‑06‑22 16:08:01
    1.3.6.1.4.1.19376.1.8.1.4.9Link.pngKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
    Uses as NameVersion
    2.16.840.1.113883.10.12.153ContainmentKgreen.png CDA AssignedEntity2005‑09‑07
    2.16.840.1.113883.10.12.316ContainmentKgreen.png CDA RelatedEntity2005‑09‑07
    RelationshipAdaptation: template 2.16.840.1.113883.10.12.319 (2005‑09‑07)
    Example
    Example
    <!-- choice: 1..1
    element hl7:assignedEntity containing template 2.16.840.1.113883.10.12.153 (dynamic)
    element hl7:relatedEntity containing template 2.16.840.1.113883.10.12.316 (dynamic)
    -->
    ItemDTCardConfDescriptionLabel
    @typeCode
    		cs0 … 1FINF
    @context​Control​Code
    		cs0 … 1FOP
    hl7:templateId
    		II1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.5 Informant
    Treetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.6
    Choice0 … 1
    The 

    informant  is either an  assignedEntity  (i.e. a person playing an identified role in the process of care) or a  relatedEntity

     (a person related to the patient)
    Elements to choose from:
    • hl7:assignedEntity containing template 2.16.840.1.113883.10.12.153 CDA AssignedEntity (2005‑09‑07)
    • hl7:relatedEntity containing template 2.16.840.1.113883.10.12.316 CDA RelatedEntity (2005‑09‑07)
    Treetree.pnghl7:assignedEntity
    		0 … 1CContains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (2005‑09‑07)PaLM Suppl. APSR 2.0‑3: 6.3.6.5 Informant
    Treetree.pnghl7:relatedEntity
    		0 … 1CContains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (2005‑09‑07)PaLM Suppl. APSR 2.0‑3: 6.3.6.5 Informant

    6.3.6.6 Additional participant in an entry - 1.3.6.1.4.1.19376.1.8.1.4.7

    6.3.6.6.1 Definition and purpose

    This Content Module is usable only within an <entry> element.

    Additional participants MAY take part in any organizer as well as in any observation of an APSR. These participants MAY be any of these 4:

    • Validator: This is the same participation as Content Validator in the header of the report: a pathologist having verified the content (of this particular subset of results).
    • Device: A device used to produce this particular subset of results.
    • Responsible: The director of a laboratory (described in a performer element at the same level) who produced this particular subset of results.
    • Transcriptionist: This is the same participation as dataEnterer in the header of the report: a staff who entered, possibly from dictation, this particular subset of results.
    6.3.6.6.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.4.7Effective Date valid from 2016‑07‑12 18:44:06
    StatusKyellow.png DraftVersion Label
    NameAdditionalParticipantAPSRDisplay NameAdditional participant in an entry APSR (Body)
    DescriptionTemplate CDA Participant (Body) (prototype, directly derived from POCD_RM000040 MIF)
    LabelPaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
    ClassificationCDA Entry Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Used by / Uses
    Used by 0 transactions and 18 templates, Uses 2 templates
    Used by as NameVersion
    1.3.6.1.4.1.19376.1.3.10.4.2ContainmentKyellow.png TNM Stage Observation (2.0)2014‑05‑13 15:45:13
    1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
    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
    1.3.6.1.4.1.19376.1.3.10.4.4ContainmentKyellow.png Assessment Scales Observation for Scoring Systems APSR2 (2.0)2016‑10‑06 13:12:00
    1.3.6.1.4.1.19376.1.3.10.9.26ContainmentKyellow.png TNM N-Observation (2.0)2014‑12‑02 16:34:50
    1.3.6.1.4.1.19376.1.3.10.9.27ContainmentKyellow.png TNM M-Observation (2.0)2014‑12‑02 16:32:30
    1.3.6.1.4.1.19376.1.3.10.9.37ContainmentKyellow.png TNM Number of nodes (2.0)2014‑12‑02 16:48:36
    1.3.6.1.4.1.19376.1.3.10.9.43ContainmentKyellow.png Assessment Scoring Item APSR 2.0 (2.0)2016‑10‑11 10:26:17
    1.3.6.1.4.1.19376.1.3.10.9.42Link.pngKyellow.png Assessment Scoring System APSR 2.0 (2.0)2016‑10‑10 11:33:36
    1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
    1.3.6.1.4.1.19376.1.3.10.3.1Link.pngKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
    1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
    1.3.6.1.4.1.19376.1.8.1.2.1Link.pngKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
    1.3.6.1.4.1.19376.1.8.1.2.2Link.pngKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
    1.3.6.1.4.1.19376.1.8.1.2.3Link.pngKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
    1.3.6.1.4.1.19376.1.8.1.2.4Link.pngKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
    1.3.6.1.4.1.19376.1.8.1.2.5Link.pngKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
    1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
    Uses as NameVersion
    2.16.840.1.113883.10.12.315ContainmentKgreen.png CDA Device2005‑09‑07
    2.16.840.1.113883.10.12.313ContainmentKgreen.png CDA PlayingEntity2005‑09‑07
    RelationshipAdaptation: template 2.16.840.1.113883.10.12.321 (2005‑09‑07)
    Example
    generated example
    <templateId root="1.3.6.1.4.1.19376.1.8.1.4.7"/><time/><participantRole classCode="ROL">
      <id root="1.2.3.999" extension="--example only--"/>  <addr>addr</addr>  <telecom value="tel:+1-12345678"/>  <!-- choice: 0..1
    element hl7:playingDevice containing template 2.16.840.1.113883.10.12.315 (dynamic)
    element hl7:playingEntity containing template 2.16.840.1.113883.10.12.313 (dynamic)
    -->
    </participantRole>
    ItemDTCardConfDescriptionLabel
    @typeCode
    		cs1 … 1R

    participant[@participationType="AUTHEN" 
    or @participationType="DEV" 
    or @participationType="RESP" 
    or @participationType="ENT"]
     CONF
    The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.10901 ParticipationType (2014‑03‑26)
    @context​Control​Code
    		cs0 … 1FOP
    hl7:templateId
    		II1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
    Treetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.7
    hl7:time
    		TS0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
    hl7:participantRole
    		1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
    Treetree.png@classCode
    		cs0 … 1FROL
    Treetree.pnghl7:id
    		II0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
    Treetree.pnghl7:addr
    		AD0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
    Treetree.pnghl7:telecom
    		TEL0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
    Choice0 … 1Elements to choose from:
    • hl7:playingDevice containing template 2.16.840.1.113883.10.12.315 CDA Device (2005‑09‑07)
    • hl7:playingEntity containing template 2.16.840.1.113883.10.12.313 CDA PlayingEntity (2005‑09‑07)
     ConstraintIf the participationType is DEV, then the playingDevice sub-element SHALL be present and the playingEntity sub-element SHALL NOT be present.  

    In all other cases the playingDevice sub-element SHALL NOT be present and the playingEntity sub-element SHALL be present.
    Treeblank.pngTreetree.pnghl7:playingDevice
    		0 … 1CContains 2.16.840.1.113883.10.12.315 CDA Device (2005‑09‑07)PaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
     ConstraintWhen the participant is a device at least one of the sub-elements code

    ,  softwareName  and

    manufacturerModelName SHALL be present.
    Treeblank.pngTreetree.pnghl7:playingEntity
    		0 … 1CContains 2.16.840.1.113883.10.12.313 CDA PlayingEntity (2005‑09‑07)PaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
     Constraintonly name(s) SHALL be given

    6.3.6.7 Anatomic Pathology Observation template – 1.3.6.1.4.1.19376.1.8.1.4.9

    6.3.6.7.1 Definition and purpose

    This Content Module is usable within a Problem Organizer.

    The “AP Observation” generic template is usable for all AP observations, including those on findings from ancillary techniques.

    An AP Observation has a status and an effective time, may describe various participants (persons, devices, organizations), may have a number of additional properties (method, interpretation, text), and may contain embedded images, comments, and sub-observations, which are also AP observations. For measurement results the UCUM system should be used.

    6.3.6.7.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.4.9Effective Date valid from 2014‑05‑14 17:09:54
    StatusKyellow.png DraftVersion Label2.0
    NameAPObservationEntryDisplay NameAP Observation Entry
    Description
    This content module is usable within a Problem organizer.
       
    The “AP Observation” generic template is usable for all AP observations, including ancillary techniques. 

    An AP observation has a status and an effective time, may describe various participants (persons, devices, organizations), may have a number of additional properties (method, interpretation, text), and may contain embedded images, comments, and sub-observations, which are also AP observations.

    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.4.9
    LabelPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
    ClassificationCDA Entry Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Used by / Uses
    Used by 0 transactions and 9 templates, Uses 10 templates
    Used by as NameVersion
    1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
    1.3.6.1.4.1.19376.1.3.10.3.1Link.pngKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
    1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
    1.3.6.1.4.1.19376.1.8.1.2.1Link.pngKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
    1.3.6.1.4.1.19376.1.8.1.2.2Link.pngKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
    1.3.6.1.4.1.19376.1.8.1.2.3Link.pngKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
    1.3.6.1.4.1.19376.1.8.1.2.4Link.pngKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
    1.3.6.1.4.1.19376.1.8.1.2.5Link.pngKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
    1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
    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
    1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
    1.3.6.1.4.1.19376.1.8.1.4.10ContainmentKyellow.png Embedded Image IHE2016‑06‑22 16:08:01
    2.16.840.1.113883.10.12.307ContainmentKgreen.png CDA RegionOfInterest2005‑09‑07
    1.3.6.1.4.1.19376.1.5.3.1.4.2ContainmentKgreen.png IHE Comment Entry (2014)2013‑12‑20
    1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
    2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA Reference2005‑09‑07
    RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
    Example
    Observation example for use case #1, estrogen receptor
    <observation classCode="OBS" moodCode="EVN" negationInd="false">
      <templateId root="1.3.6.1.4.1.19376.1.8.1.4.9"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="16112-5" codeSystem="2.16.840.1.113883.6.1" displayName="Estrogen receptor [Interpretation] in Tissue"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>
        <low value="20161129162112"/>  </effectiveTime>      <value xsi:type="CD" code="416053008" displayName="Estrogen receptor positive tumor (disorder)" codeSystem="2.16.840.1.113883.6.96"/>  <methodCode code="0107" displayName="Microscopy" codeSystem="2.16.840.1.113883.5.84"/>  <performer>
        <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'CDA Performer IHE (Body)' (dynamic) -->
      </performer>      <author>
        <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) -->
      </author>      <informant>
        <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Body) APSR2' (dynamic) -->
      </informant>      <participant>
        <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (dynamic) -->
      </participant>      <entryRelationship xsi:type="" typeCode="COMP">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (dynamic) -->
      </entryRelationship>      <entryRelationship xsi:type="" typeCode="COMP">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (dynamic) -->
      </entryRelationship>      <entryRelationship xsi:type="" typeCode="COMP">
        <!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' (dynamic) -->
      </entryRelationship>      <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 0..* O -->
      <reference>
        <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (dynamic) -->
      </reference>    </observation>
    ItemDTCardConfDescriptionLabel
    hl7:observation
    		0 … *RPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
    Treetree.png@classCode
    		cs1 … 1FOBS
    Treetree.png@moodCode
    		cs1 … 1FEVN
    Treetree.png@negationInd
    		bl0 … 1 
    Treetree.pnghl7:templateId
    		II1 … 1MPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.9
    Treetree.pnghl7:id
    		II0 … *RPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
    Treetree.pnghl7:code
    		CE (extensible)1 … 1MThe Anatomic pathology observation code should be taken from a reference terminology, preferably the LOINC terminology. National terminologies may be used.PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
    Treeblank.pngTreetree.png@code
    		CONF1 … 1Feach_code_for_observable_entities_or_a_specific_procedure
    Treeblank.pngTreetree.png@codeSystem
    		1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
    Treeblank.pngTreetree.png@codeSystemName
    		1 … 1FLOINC
    Treeblank.pngTreetree.png@displayName
    		1 … 1Fsee_above
     Example<code code="59847-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Histology and Behavior ICD-O-3"/>
    Treetree.pnghl7:text
    		ED0 … 1RNarrative text about the observationPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
    Treetree.pnghl7:statusCode
    		CS (required)1 … 1MThe 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.    		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
     CONF
    The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 (DYNAMIC)
    Alert.pngError: Cannot find value set "1.3.6.1.4.1.19376.1.3.11.2"
    Treetree.pnghl7:effectiveTime
    		IVL_TS1 … 1MDate and time the observation has been made
    		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
    Treetree.pnghl7:value
    		ANY0 … *RObservation values using the appropriate data type.


    Numeric results use data type PQ, which includes the unit. The result is absent in case of ‘aborted’ observation.


    		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
     ConstraintThe default data type, cardinalities and value set for the <value> element are dependant on the type of observation.
     CONF
    The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.11 AP Observation (2015‑11‑22 12:20:34)
     Example
    for observation on tumor type
    <value code="8500/3" codeSystem="2.16.840.1.113883.6.43.1" codeSystemName="ICD-O-3" displayName="Invasive carcinoma of the breast, no special type"/>
    Treetree.pnghl7:interpretationCode
    		CE (extensible)0 … 1R

    One or more codes interpreting the result, expressed with ObservationInterpretation vocabulary (e.g., H = high, L = low). 

      This element may be coded with other values than those of the ObservationInterpretation vocabulary, given that the coding strength is CWE (coded with exceptions).

    		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
     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 … 1RPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
     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 … 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 TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
    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 TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
    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 TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
    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 TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
    Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.7']]
    Treetree.pnghl7:entryRelationship
    		0 … *RSub-Observation


    The result obtained for an observation may lead to an additional AP observation to refine this result. This sub-observation is again an Anatomic Pathology Observation. 

       
       
    Source:     Source: PaLM TF Suppl. APSR 2.0-3
   : 6.3.6.7

    Contains 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54)    		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
    Treeblank.png where [@typeCode='COMP'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.9']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treetree.pnghl7:entryRelationship
    		0 … *REmbedded image. 


    This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest. 

    Source: PaLM TF Suppl. APSR 2.0-3 : 6.3.6.8

    Contains 1.3.6.1.4.1.19376.1.8.1.4.10 Embedded Image IHE (2016‑06‑22 16:08:01)    		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
    Treeblank.png where [@typeCode='COMP'] [hl7:observationMedia [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.10']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treetree.pnghl7:entryRelationship
    		0 … *RRegion of Interest

    Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (2005‑09‑07)    		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
    Treeblank.png where [@typeCode='COMP'] [hl7:regionOfInterest [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.307']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
     ConstraintThis observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest.
    In the latter case by an entryRelationship @typeCode="SUBJ"
    Treetree.pnghl7:entryRelationship
    		0 … *RAnnotation comment

    Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20)    		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
    Treeblank.png where [hl7:act [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.20.1.40'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.2']]]
    Treeblank.pngTreetree.png@typeCode
    		cs0 … 1FCOMP
    Included1 … *M from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
    Specimen identification
     Example
    Example for specimen referencing
    <specimen>
      <!-- which specimen is used for this observation -->
      <specimenRole>
        <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="slide_A_1_PR"/>  </specimenRole>    </specimen>
    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
    Treetree.pnghl7:reference
    		0 … *RReference to an external document, or to external observations, e.g. concerning molecular pathology or  genetic testing report
    Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)    		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

    6.3.6.8 Embedded Image – 1.3.6.1.4.1.19376.1.8.1.4.10

    6.3.6.8.1 Definition and purpose

    This Content Module is usable within an <entry> element, in relationship with a display anchor carried in the referencedObject attribute of a <renderMultimedia> element in the <text> element of the <section> holding this <entry>.


    The <observationMedia> element carries an image, embedded in B64. This element may be standalone, or encapsulated within a <regionOfInterest> element which defines an overlay shape to focus on a part of the image.

    This <observationMedia> element embeds the image binary data, encoded in B64.

    6.3.6.8.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.4.10Effective Date valid from 2016‑06‑22 16:08:01
    StatusKyellow.png DraftVersion Label
    NameEmbeddedImageIHEDisplay NameEmbedded Image IHE
    Description
    Template CDA ObservationMedia (prototype, directly derived from POCD_RM000040 MIF)


    This Content Module is usable within an <entry> element, in relationship with a display anchor carried in the referencedObject attribute of a <renderMultimedia> element in the <text> element of the <section> holding this <entry>.

    The <observationMedia> element carries an image, embedded in B64. This element may be standalone, or encapsulated within a <regionOfInterest> element which defines an overlay shape to focus on a part of the image.

    This <observationMedia> element embeds the image binary data, encoded in B64. 

    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.4.10
    LabelPaLM TF‑3: 6.3.4.14 Embedded image
    ClassificationCDA Entry Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Used by / Uses
    Used by 0 transactions and 9 templates, Uses 5 templates
    Used by as NameVersion
    1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
    1.3.6.1.4.1.19376.1.3.10.3.1Link.pngKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
    1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
    1.3.6.1.4.1.19376.1.8.1.2.1Link.pngKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
    1.3.6.1.4.1.19376.1.8.1.2.2Link.pngKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
    1.3.6.1.4.1.19376.1.8.1.2.3Link.pngKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
    1.3.6.1.4.1.19376.1.8.1.2.4Link.pngKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
    1.3.6.1.4.1.19376.1.8.1.2.5Link.pngKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
    1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
    Uses as NameVersion
    1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
    1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.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
    1.3.6.1.4.1.19376.1.5.3.1.4.2ContainmentKgreen.png IHE Comment Entry (2014)2013‑12‑20
    RelationshipSpecialization: template 2.16.840.1.113883.10.12.304 (2005‑09‑07)
    Example
    generated example
    <observationMedia classCode="OBS" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.8.1.4.10"/>  <id root="1.2.3.999" extension="--example only--"/>  <languageCode code="en"/>  <value mediaType="application" representation="B64"/>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 1..1 M -->
      <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>      <entryRelationship negationInd="false" typeCode="SUBJ" inversionInd="true" contextConductionInd="true">
        <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.4.2 'IHE Comment Entry' (2013-12-20T00:00:00) -->
      </entryRelationship>    </observationMedia>
    ItemDTCardConfDescriptionLabel
    hl7:observationMedia
    		0 … *REmbedded ImagePaLM TF‑3: 6.3.4.14 Embedded image
    Treetree.png@classCode
    		cs1 … 1FOBS
    Treetree.png@moodCode
    		cs1 … 1FEVN
    Treetree.pnghl7:templateId
    		II1 … 1MPaLM TF‑3: 6.3.4.14 Embedded image
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.10
    Treetree.pnghl7:id
    		II0 … *R

       The ID attribute is pointed to by the anchor in the referencedObject attribute of a <renderMultimedia> element in the <text> element of the <section> holding this <entry>.

    		PaLM TF‑3: 6.3.4.14 Embedded image
    Treetree.pnghl7:value
    		1 … 1RPaLM TF‑3: 6.3.4.14 Embedded image
    Treeblank.pngTreetree.png@representation
    		cs1 … 1FB64
    Treeblank.pngTreetree.png@mediaType
    		cs1 … 1RThe mediaType attribute specifies the type of media/application to be used to display the image. For instance ‘image/gif’ or ‘image/jpeg’.

     


     CONF
    The value of @mediaType shall be drawn from value set 2.16.840.1.113883.1.11.14824 MediaType (DYNAMIC)
     ConstraintThe <value> element contains the image encoded in Base 64. This is indicated by the value “B64”of attribute representation. 
    Included1 … 1M 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 … 1MRequired 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:performer
    		0 … *CContains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)PaLM TF‑3: 6.3.4.14 Embedded image
    Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
    Treetree.pnghl7:author
    		0 … *CContains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)PaLM TF‑3: 6.3.4.14 Embedded image
    Treeblank.png where [hl7:author [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.2']]]
    Treetree.pnghl7:informant
    		0 … *RContains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (2016‑07‑08 11:22:58)PaLM TF‑3: 6.3.4.14 Embedded image
    Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.6']]
    Treetree.pnghl7:entryRelationship
    		0 … *RComment on this image.

    Source: PCC TF-2: 6.3.4.6
    Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20)    		PaLM TF‑3: 6.3.4.14 Embedded image
    Treeblank.png where [@typeCode='SUBJ'] [hl7:act [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.20.1.40'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.2']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FSUBJ
    Treeblank.pngTreetree.png@inversionInd
    		bl0 … 1Ftrue

    6.3.6.9 X Specimen Identified - 1.3.6.1.4.1.19376.1.3.10.9.1

    6.3.6.9.1 Definition and purpose

    This Specimen Identification <entry> provides the machine-readable links between any type of procedure or observation or embedded image or containers to the specimen, on that this procedure is performed (parent specimen), or from which this observation or image is obtained. It is required when more than one specimen is documented at this level. It is only used in PaLM templates for Problem Organizer, Specimen Procedure Steps, Observations, Embedded images, and Containers in Specimen Procedure Steps.

    6.3.6.9.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.3.10.9.1Effective Date valid from 2014‑12‑22 15:54:30
    StatusKyellow.png DraftVersion Label
    NameSpecimenIdentifiedDisplay NameX Specimen Identified
    Description
    Template CDA Specimen (prototype, directly derived from POCD_RM000040 MIF)

    Entry template for linking specimen ID to observation or to procedure.
    Required in XD-LAB when more than one specimen is documented at this level. 
    LabelPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
    ClassificationCDA Entry Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Used by / Uses
    Used by 0 transactions and 32 templates, Uses 0 templates
    Used by as NameVersion
    1.3.6.1.4.1.19376.1.3.10.4.1IncludeKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
    1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
    1.3.6.1.4.1.19376.1.8.1.2.6Link.pngKyellow.png Procedure Steps Section (2.0)2014‑05‑13 19:33:12
    1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
    1.3.6.1.4.1.19376.1.3.10.4.2IncludeKyellow.png TNM Stage Observation (2.0)2014‑05‑13 15:45:13
    1.3.6.1.4.1.19376.1.3.10.4.3IncludeKyellow.png ICD-O-3 Typing and Grading Observation (2.0)2015‑11‑29 17:03:18
    1.3.6.1.4.1.19376.1.3.10.4.4IncludeKyellow.png Assessment Scales Observation for Scoring Systems APSR2 (2.0)2016‑10‑06 13:12:00
    1.3.6.1.4.1.19376.1.3.10.9.22IncludeKyellow.png CDA Supply Container APSR2 (2.0)2016‑07‑29 12:09:33
    1.3.6.1.4.1.19376.1.3.10.9.25IncludeKyellow.png TNM T-Observation (2.0)2014‑12‑02 15:54:17
    1.3.6.1.4.1.19376.1.3.10.9.26IncludeKyellow.png TNM N-Observation (2.0)2014‑12‑02 16:34:50
    1.3.6.1.4.1.19376.1.3.10.9.27IncludeKyellow.png TNM M-Observation (2.0)2014‑12‑02 16:32:30
    1.3.6.1.4.1.19376.1.3.10.9.28IncludeKyellow.png TNM Grading (2.0)2015‑11‑15 13:01:18
    1.3.6.1.4.1.19376.1.3.10.9.29IncludeKyellow.png TNM R-status (2.0)2015‑06‑30 13:38:30
    1.3.6.1.4.1.19376.1.3.10.9.34IncludeKyellow.png TNM Lymphatic Invasion (2.0)2015‑11‑16 14:01:58
    1.3.6.1.4.1.19376.1.3.10.9.35IncludeKyellow.png TNM Venous Invasion (2.0)2015‑11‑16 13:40:28
    1.3.6.1.4.1.19376.1.3.10.9.36IncludeKyellow.png TNM Perineural Invasion (2.0)2015‑11‑11 16:13:40
    1.3.6.1.4.1.19376.1.3.10.9.37IncludeKyellow.png TNM Number of nodes (2.0)2014‑12‑02 16:48:36
    1.3.6.1.4.1.19376.1.3.10.9.38IncludeKyellow.png ICD-O-3 Behavior (2.0)2015‑12‑03 09:11:54
    1.3.6.1.4.1.19376.1.3.10.9.39IncludeKyellow.png ICD-O-3 Differentiation (2.0)2015‑12‑09 17:12:30
    1.3.6.1.4.1.19376.1.3.10.9.40IncludeKyellow.png ICD-O-3 Morphology (1.0)2015‑11‑29 15:45:48
    1.3.6.1.4.1.19376.1.3.10.9.41IncludeKyellow.png ICD-O-3 Topography (2.0)2015‑11‑16 18:38:07
    1.3.6.1.4.1.19376.1.3.10.9.42IncludeKyellow.png Assessment Scoring System APSR 2.0 (2.0)2016‑10‑10 11:33:36
    1.3.6.1.4.1.19376.1.3.10.9.43IncludeKyellow.png Assessment Scoring Item APSR 2.0 (2.0)2016‑10‑11 10:26:17
    1.3.6.1.4.1.19376.1.8.1.3.6IncludeKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
    1.3.6.1.4.1.19376.1.3.10.3.1Link.pngKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
    1.3.6.1.4.1.19376.1.8.1.2.1Link.pngKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
    1.3.6.1.4.1.19376.1.8.1.2.2Link.pngKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
    1.3.6.1.4.1.19376.1.8.1.2.3Link.pngKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
    1.3.6.1.4.1.19376.1.8.1.2.4Link.pngKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
    1.3.6.1.4.1.19376.1.8.1.2.5Link.pngKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
    1.3.6.1.4.1.19376.1.8.1.4.10IncludeKyellow.png Embedded Image IHE2016‑06‑22 16:08:01
    1.3.6.1.4.1.19376.1.8.1.4.9Link.pngKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
    Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
    RelationshipSpecialization: template 2.16.840.1.113883.10.12.322 (2005‑09‑07)
    Example
    Example
    <specimen typeCode="SPC">
      <specimenRole classCode="SPEC">
        <id root="1.2.3.999" extension="--example only, coming from the LIS--"/>  </specimenRole>    </specimen>
    ItemDTCardConfDescriptionLabel
    hl7:specimen
    		0 … 1RRequired 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
    Treetree.png@typeCode
    		cs0 … 1FSPC
    Treetree.pnghl7:specimenRole
    		1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
    Treeblank.pngTreetree.png@classCode
    		cs0 … 1FSPEC
    Treeblank.pngTreetree.pnghl7:id
    		II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified

    6.3.6.10 UICC/AJCC TNM Staging and Grading - 1.3.6.1.4.1.19376.1.3.10.4.2

    6.3.6.10.1 Definition and purpose

    The UICC/AJCC TNM <entry> Content Modul contains in machine-readable form all the information concerning a TNM formula for a problem investigated. It is a constraint version of an AP Generic observation <entry> Content Module. It is usable within a Problem Organizer <entry> Content Module only.

    This Content Module structures the machine-readable data, which characterize the staging and grading of a malignant Tumor according the UICC/AJCC regulations for the TNM system. A series of supporting templates is used for all the detailed descriptions of the elements of the TNM system.

    6.2.6.12.1-1 1.jpeg

    Figure 6.3.6.10.1-1 CDA-RMIM of the UICC/AJCC TNM <entry>

    6.3.6.10.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.3.10.4.2Effective Date valid from 2014‑05‑13 15:45:13
    StatusKyellow.png DraftVersion Label2.0
    NameTNMStageObservationDisplay NameTNM Stage Observation
    DescriptionTemplate CDA Observation (prototype, directly derived from POCD_RM000040 MIF)

    TNM stage with supporting categories
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.2
    LabelPaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
    ClassificationCDA Entry Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Used by / Uses
    Used by 0 transactions and 1 template, Uses 17 templates
    Used by as NameVersion
    1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
    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
    1.3.6.1.4.1.19376.1.3.10.9.32ContainmentKyellow.png TNM y (2.0)2015‑06‑22 17:28:17
    1.3.6.1.4.1.19376.1.3.10.9.30ContainmentKyellow.png TNM a (2.0)2015‑06‑22 15:13:46
    1.3.6.1.4.1.19376.1.3.10.9.31ContainmentKyellow.png TNM r (2.0)2015‑06‑22 17:38:42
    1.3.6.1.4.1.19376.1.3.10.9.25ContainmentKyellow.png TNM T-Observation (2.0)2014‑12‑02 15:54:17
    1.3.6.1.4.1.19376.1.3.10.9.26ContainmentKyellow.png TNM N-Observation (2.0)2014‑12‑02 16:34:50
    1.3.6.1.4.1.19376.1.3.10.9.27ContainmentKyellow.png TNM M-Observation (2.0)2014‑12‑02 16:32:30
    1.3.6.1.4.1.19376.1.3.10.9.33ContainmentKyellow.png TNM Serum tumor markers (2.0)2015‑11‑06 14:28:44
    1.3.6.1.4.1.19376.1.3.10.9.34ContainmentKyellow.png TNM Lymphatic Invasion (2.0)2015‑11‑16 14:01:58
    1.3.6.1.4.1.19376.1.3.10.9.35ContainmentKyellow.png TNM Venous Invasion (2.0)2015‑11‑16 13:40:28
    1.3.6.1.4.1.19376.1.3.10.9.36ContainmentKyellow.png TNM Perineural Invasion (2.0)2015‑11‑11 16:13:40
    1.3.6.1.4.1.19376.1.3.10.9.28ContainmentKyellow.png TNM Grading (2.0)2015‑11‑15 13:01:18
    1.3.6.1.4.1.19376.1.3.10.9.29ContainmentKyellow.png TNM R-status (2.0)2015‑06‑30 13:38:30
    RelationshipSpecialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 (2014‑05‑14 17:09:54)
    Example
    Generated example
    <observation classCode="OBS" moodCode="ENV" negationInd="false">
      <templateId root="1.3.6.1.4.1.19376.1.3.10.4.2"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="21902-2" codeSystem="2.16.840.1.113883.6.1"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>
        <low value="20170712152253"/>  </effectiveTime>      <value xsi:type="CD" code="IIA" displayName="stage IIA" codeSystem="2.16.840.1.113883.15.6"/>  <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 -->
      <entryRelationship>
        <!-- template 1.3.6.1.4.1.19376.1.3.10.9.32 'TNM y' (2015-06-22T17:28:17) -->
      </entryRelationship>      <entryRelationship>
        <!-- template 1.3.6.1.4.1.19376.1.3.10.9.30 'TNM a ' (2015-06-22T15:13:46) -->
      </entryRelationship>      <entryRelationship>
        <!-- template 1.3.6.1.4.1.19376.1.3.10.9.31 'TNM r' (2015-06-22T17:38:42) -->
      </entryRelationship>      <entryRelationship>
        <!-- template 1.3.6.1.4.1.19376.1.3.10.9.25 'TNM T-Observation' (2014-12-02T15:54:17) -->
      </entryRelationship>      <entryRelationship>
        <!-- template 1.3.6.1.4.1.19376.1.3.10.9.26 'TNM N-Observation' (2014-12-02T16:34:50) -->
      </entryRelationship>      <entryRelationship>
        <!-- template 1.3.6.1.4.1.19376.1.3.10.9.27 'TNM M-Observation' (2014-12-02T16:32:30) -->
      </entryRelationship>      <entryRelationship>
        <!-- template 1.3.6.1.4.1.19376.1.3.10.9.33 'TNM Serum tumor markers' (2015-11-06T14:28:44) -->
      </entryRelationship>      <entryRelationship>
        <!-- template 1.3.6.1.4.1.19376.1.3.10.9.34 'TNM Lymphatic Invasion' (2015-11-16T14:01:58) -->
      </entryRelationship>      <entryRelationship>
        <!-- template 1.3.6.1.4.1.19376.1.3.10.9.35 'TNM Venous Invasion' (2015-11-16T13:40:28) -->
      </entryRelationship>      <entryRelationship>
        <!-- template 1.3.6.1.4.1.19376.1.3.10.9.36 'TNM Perineural Invasion' (2015-11-11T16:13:40) -->
      </entryRelationship>      <entryRelationship>
        <!-- template 1.3.6.1.4.1.19376.1.3.10.9.28 'TNM Grading' (2015-11-15T13:01:18) -->
      </entryRelationship>      <entryRelationship>
        <!-- template 1.3.6.1.4.1.19376.1.3.10.9.29 'TNM R-status' (2015-06-30T13:38:30) -->
      </entryRelationship>    </observation>
    ItemDTCardConfDescriptionLabel
    hl7:observation
    		0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
    Treetree.png@classCode
    		cs1 … 1FOBS
    Treetree.png@moodCode
    		cs1 … 1FENV
    Treetree.png@negationInd
    		bl0 … 1 
    Treetree.pnghl7:templateId
    		II1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.3.10.4.2
    Treetree.pnghl7:id
    		II0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
    Treetree.pnghl7:code
    		CE (extensible)1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
     CONF
    @code shall be "21902-2"
    @codeSystem shall be "2.16.840.1.113883.6.1"
    @codeSystemName shall be "LOINC"
    or
    @code shall be "tnmStage"
    @codeSystem shall be "1.2.276.0.76.3.1.131.1.5.1"
    @codeSystemName shall be "DKG Coding Scheme"
    @displayName shall be "tumor stage"
    Treetree.pnghl7:text
    		ED0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
     Example<text> PATHOLOGIC STAGE (AJCC 7th Edition): IIA </text>
    Treetree.pnghl7:statusCode
    		CS (required)1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
     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 1.3.6.1.4.1.19376.1.3.11.2 (DYNAMIC)
    Alert.pngError: Cannot find value set "1.3.6.1.4.1.19376.1.3.11.2"
    or
    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: 6.3.6.10 TNM
    Treetree.pnghl7:value
    		CD (extensible)0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
     CONF
    The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.46 UICC Stage (2017‑07‑21 10:43:31)
    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: 6.3.6.10 TNM
    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: 6.3.6.10 TNM
    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: 6.3.6.10 TNM
    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: 6.3.6.10 TNM
    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
    Treetree.pnghl7:entryRelationship
    		0 … 1Rstaged after multimodal (neoadjuvant) therapy

    Contains 1.3.6.1.4.1.19376.1.3.10.9.32 TNM y (2015‑06‑22 17:28:17)    		PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
    Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.32']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FSPRT
    Treetree.pnghl7:entryRelationship
    		0 … 1Rfirst staged at autopsy
    Contains 1.3.6.1.4.1.19376.1.3.10.9.30 TNM a (2015‑06‑22 15:13:46)    		PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
    Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.30']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FSPRT
    Treetree.pnghl7:entryRelationship
    		0 … 1Rstaged after relapse
    Contains 1.3.6.1.4.1.19376.1.3.10.9.31 TNM r (2015‑06‑22 17:38:42)    		PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
    Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.31']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FSPRT
    Treetree.pnghl7:entryRelationship
    		1 … 1RT: T category of TNM

    Contains 1.3.6.1.4.1.19376.1.3.10.9.25 TNM T-Observation (2014‑12‑02 15:54:17)    		PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
    Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.25']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FSPRT
    Treetree.pnghl7:entryRelationship
    		1 … 1RN: N category of TNM

    Contains 1.3.6.1.4.1.19376.1.3.10.9.26 TNM N-Observation (2014‑12‑02 16:34:50)    		PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
    Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.26']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FSPRT
    Treetree.pnghl7:entryRelationship
    		0 … 1RM: M category of TNM

    Contains 1.3.6.1.4.1.19376.1.3.10.9.27 TNM M-Observation (2014‑12‑02 16:32:30)    		PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
    Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.27']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FSPRT
    Treetree.pnghl7:entryRelationship
    		0 … 1RSerum tumor markers stage descriptor
    Contains 1.3.6.1.4.1.19376.1.3.10.9.33 TNM Serum tumor markers (2015‑11‑06 14:28:44)    		PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
    Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.33']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FSPRT
    Treetree.pnghl7:entryRelationship
    		0 … 1RDescriptor for lymphatic invasion
    Contains 1.3.6.1.4.1.19376.1.3.10.9.34 TNM Lymphatic Invasion (2015‑11‑16 14:01:58)    		PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
    Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.34']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FSPRT
    Treetree.pnghl7:entryRelationship
    		0 … 1RDescriptor for venous invasion

    Contains 1.3.6.1.4.1.19376.1.3.10.9.35 TNM Venous Invasion (2015‑11‑16 13:40:28)    		PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
    Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.35']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FSPRT
    Treetree.pnghl7:entryRelationship
    		0 … 1RDescriptor for perineurial invasion

    Contains 1.3.6.1.4.1.19376.1.3.10.9.36 TNM Perineural Invasion (2015‑11‑11 16:13:40)    		PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
    Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.36']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FSPRT
    Treetree.pnghl7:entryRelationship
    		1 … 1RTNM-Grading
    Contains 1.3.6.1.4.1.19376.1.3.10.9.28 TNM Grading (2015‑11‑15 13:01:18)    		PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
    Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.28']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FSPRT
    Treetree.pnghl7:entryRelationship
    		0 … 1RStatus of residual tumor
    Contains 1.3.6.1.4.1.19376.1.3.10.9.29 TNM R-status (2015‑06‑30 13:38:30)    		PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
    Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.29']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FSPRT

    6.3.6.11 ICD-O-3 Typing and Grading - 1.3.6.1.4.1.19376.1.3.10.4.3

    6.3.6.11.1 Definition and purpose

    The ICD-O-3 Typing and Grading<entry> Content Modul contains in machine-readable form all the information concerning ICD-O-3 Typing and Grading for a problem investigated. It is a constraint version of an AP Generic observation <entry> Content Module. It is usable within a Problem Organizer <entry> Content Module only.

    This Content Module structures the machine-readable data, which characterize the typing and grading of a tumor or a systemic malignancy according the WHO regulations for the ICD-O-3 system. A series of supporting templates is used for all the detailed descriptions of the elements of the ICD-O-3 system.

    6.2.6.13.1-1 1.jpeg

    Figure 6.3.6.11.1-1 CDA-RMIM of the ICD-O-3 <entry>

    6.3.6.11.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.3.10.4.3Effective Date valid from 2015‑11‑29 17:03:18
    StatusKyellow.png DraftVersion Label2.0
    NameICD-O-3TypingGradingDisplay NameICD-O-3 Typing and Grading Observation
    DescriptionTemplate CDA Observation (prototype, directly derived from POCD_RM000040 MIF)

    Entry template for observation on ICD-O-3 Typing and Grading
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.3
    LabelPaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
    ClassificationCDA Entry Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Used by / Uses
    Used by 0 transactions and 0 templates, Uses 9 templates
    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
    1.3.6.1.4.1.19376.1.3.10.9.38ContainmentKyellow.png ICD-O-3 Behavior (2.0)2015‑12‑03 09:11:54
    1.3.6.1.4.1.19376.1.3.10.9.39ContainmentKyellow.png ICD-O-3 Differentiation (2.0)2015‑12‑09 17:12:30
    1.3.6.1.4.1.19376.1.3.10.4.4ContainmentKyellow.png Assessment Scales Observation for Scoring Systems APSR2 (2.0)2016‑10‑06 13:12:00
    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
    <observation classCode="OBS" moodCode="EVN" negationInd="false">
      <templateId root="1.3.6.1.4.1.19376.1.3.10.4.3"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_ICDO"/>  <code code="31205-8" codeSystem="2.16.840.1.113883.6.1" displayName="Histology ICD-O-3 Cancer"/>  <statusCode code="completed"/>  <effectiveTime>
        <low value="201001041405-0500"/>  </effectiveTime>      <value xsi:type="CD" code="8500/3" codeSystem="2.16.840.1.113883.6.43.1"/>  <author>
        <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->
      </author>      <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 1..* R -->
      <specimen typeCode="SPC">
        <specimenRole classCode="SPEC">
          <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_slide_A1_HE"/>    </specimenRole>      </specimen>      <entryRelationship typeCode="SPRT">
        <!-- template 1.3.6.1.4.1.19376.1.3.10.9.38 'ICD-O-3 Behavior' (2015-12-03T09:11:54), not used in use case #1 -->
      </entryRelationship>      <entryRelationship typeCode="SPRT">
        <!-- template 1.3.6.1.4.1.19376.1.3.10.9.39 'ICD-O-3 Differentiation' (2015-12-09T17:12:30) -->
      </entryRelationship>      <entryRelationship typeCode="COMP">
        <!-- template 1.3.6.1.4.1.19376.1.3.10.4.4 'Assessment Scales Observation for Scoring Systems APSR2' (2016-10-06T13:12:00) -->
      </entryRelationship>      <reference>
        <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
      </reference>    </observation>
    ItemDTCardConfDescriptionLabel
    hl7:observation
    		0 … 1RFirst four digits of Morphology axis code. A complete code consists of 6 digits (for morphology, behavior and grading), the latter both separated by "/" after the 4th digit in morphology.

    Behavior and differentiation are coded as sub-observations
    		PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
    Treetree.png@classCode
    		cs1 … 1FOBS
    Treetree.png@moodCode
    		cs1 … 1FEVN
    Treetree.png@negationInd
    		bl0 … 1 
    Treetree.pnghl7:templateId
    		II1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.3.10.4.3
    Treetree.pnghl7:id
    		II0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
    Treetree.pnghl7:code
    		CV (extensible)1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
     CONF
    @code shall be "31205-8"
    @codeSystem shall be "2.16.840.1.113883.6.1"
    @codeSystemName shall be "LOINC"
    @displayName shall be "Histology ICD-O-3 Cancer"
    or
    @code shall be "397005006"
    @codeSystem shall be "2.16.840.1.113883.6.96"
    @codeSystemName shall be "SNOMED-CT"
    @displayName shall be "WHO tumor classification (observable entity)"
    Treetree.pnghl7:statusCode
    		CS (required)1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
     CONF
    The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 (DYNAMIC)
    Alert.pngError: Cannot find value set "1.3.6.1.4.1.19376.1.3.11.2"
    Treetree.pnghl7:effectiveTime
    		IVL_TS1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
    Treetree.pnghl7:value
    		CD1 … 1RFirst four digits of Morphology axis codePaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
     CONF
    The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.33 ICD-O-3 Morphology (2015‑11‑13 14:08:46)
     Example
    for use case #1: invasive breast cancer, NST, well differentiated
    <value xsi:type="CD" code="8500" codeSystem="2.16.840.1.113883.6.43.1"/>
    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: 6.3.6.11 ICD‑O‑3
    Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
    Treetree.pnghl7:author
    		II0 … 1CContains 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: 6.3.6.11 ICD‑O‑3
    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: 6.3.6.11 ICD‑O‑3
    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: 6.3.6.11 ICD‑O‑3
    Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.7']]
    Included1 … *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
    		1 … *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
    		1 … 1R5th digit in the morphology axis code
    Contains 1.3.6.1.4.1.19376.1.3.10.9.38 ICD-O-3 Behavior (2015‑12‑03 09:11:54)    		PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
    Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.38']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FSPRT
    Treetree.pnghl7:entryRelationship
    		0 … 1R6th digit in the morphology axis code
    Contains 1.3.6.1.4.1.19376.1.3.10.9.39 ICD-O-3 Differentiation (2015‑12‑09 17:12:30)    		PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
    Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.39']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FSPRT
    Treetree.pnghl7:entryRelationship
    		0 … 1Roptional grading by a scoring system, e.g. by means of the Elston-Ellis-Scoring-System in case of invasive breast cancer (ICD-O C50)

    Contains 1.3.6.1.4.1.19376.1.3.10.4.4 Assessment Scales Observation for Scoring Systems APSR2 (2016‑10‑06 13:12:00)    		PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
    Treeblank.png where [@typeCode='COMP'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.4.4']]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treetree.pnghl7:reference
    		0 … *RContains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

    6.3.6.12 Assessment Scales for Scoring systems - 1.3.6.1.4.1.19376.1.3.10.4.4

    6.3.6.12.1 Definition and purpose

    The Assessment Scales <entry> Content Modul contains in machine-readable form all the information concerning (semi)quantitative scoring systems often used for describing a tumor grading for a problem investigated. It is a constraint version of an AP Generic observation <entry> Content Module. It is usable within the ICD-O-3 Typing and Grading <entry> or within a Problem Organizer <entry> Content Module.

    This Content Module structures the machine-readable data, which characterize the grading components of a tumor or a systemic disease according specific regulations.

    6.2.6.14.1-1.jpg

    Figure 6.3.6.12.1-1 CDA-RMIM of an Assessment Scales <entry>

    6.3.6.12.2 Specification and Example
    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)

    VOLUME 4 - VALUE SETS

    1 Introduction

    This document, Volume 4 of the Suppl. APSR 2.0 for the IHE Pathology and Laboratory Medicine (PaLM) Technical Framework, defines value sets used in the IHE Anatomic Pathology profiles.

    1.1 Overview of IHE

    Integrating the Healthcare Enterprise (IHE) is an international initiative to promote the use of standards to achieve interoperability among health information technology (HIT) systems and effective use of electronic health records (EHRs). IHE provides a forum for care providers, HIT experts and other stakeholders in several clinical and operational domains to reach consensus on standards-based solutions to critical interoperability issues. The primary output of IHE is system implementation guides, called IHE Profiles. IHE publishes each profile through a well-defined process of public review and trial implementation and gathers profiles that have reached final text status into an IHE Technical Framework, of which this volume is a part. For more general information regarding IHE, refer to IHE International website. It is strongly recommended that, prior to reading this volume, the reader familiarizes themselves with the concepts defined in the IHE Technical Frameworks General Introduction.

    1.2 Overview of the PaLM Technical Framework

    The content of this entire section is copied from section 1 of Volume 3 of PaLM TF.

    1.3 Audience

    The intended audience of IHE Technical Frameworks Volume 4 is:

    • IT departments of healthcare institutions
    • Technical staff of vendors participating in the IHE initiative
    • Experts involved in standards development

    1.4 Relationship to Standards

    The IHE PaLM Technical Framework identifies functional components of a distributed healthcare environment (referred to as IHE actors), solely from the point of view of their interactions in the healthcare enterprise. At its current level of development, it defines a coordinated set of transactions based on HL7, IETF, ISO, CLSI, OASIS and W3C standards. As the scope of the IHE initiative expands, transactions based on other international standards may be included as required. In some cases, IHE recommends selection of specific options supported by these standards; however, IHE does not introduce technical choices that contradict conformance to these standards. If errors in or extensions to existing standards are identified, IHE’s policy is to report them to the appropriate standards bodies for resolution within their conformance and standards evolution strategy. IHE is therefore an implementation framework, not a standard. Conformance claims for products must still be made in direct reference to specific standards. In addition, vendors who have implemented IHE integration capabilities in their products may publish IHE Integration Statements to communicate their products’ capabilities. Vendors publishing IHE Integration Statements accept full responsibility for their content. By comparing the IHE Integration Statements from different products, a user familiar with the IHE concepts of actors and integration profiles can determine the level of integration between them.

    1.5 Relationship to Real-World Architectures

    1.6 Comments

    1.7 Copyright Permissions

    1.8 IHE TF Development and Maintenance Process

    The IHE Pathology and Laboratory Medicine Technical Framework is being continuously extended and maintained by the IHE PaLM Technical committee. The development and maintenance process of the Framework follows a number of principles to ensure stability of the specification so that both vendors and users may use it reliably in specifying, developing and acquiring systems with IHE integration capabilities. The first of these principles is that any extensions, clarifications and corrections to the Technical Framework must maintain backward compatibility with previous versions of the framework in order to maintain interoperability with systems that have implemented IHE Actors and Integration Profiles defined there.

    1.9 Glossary

    The IHE Glossary can be found as an appendix to the IHE Technical Frameworks General Introduction, available on this page.

    2 Overview

    Volume 4 is comprised of several distinct sections:

    • Section 1 provides background and reference material.
    • Section 2 presents the conventions used in this volume to define the content modules.
    • Section 3 provides an overview of Open issues.
    • Section 4 shows the Value sets with their bindings.

    3 Open Issues

    None

    4 APSR Value Sets

    There are both extensional and intensional value sets specifically used for APSR.

    4.1 Generic AP Observation Codes 1.3.6.1.4.1.19376.1.3.11.11

    Id1.3.6.1.4.1.19376.1.3.11.11Effective Date valid from 2015‑11‑22 12:20:34
    StatusKyellow.png DraftVersion Label
    NameAP-ObservationDisplay NameAP Observation
    DescriptionGeneric codes for AP Observations of all kind, including results of ancillary techniques (immunohistochemistry, in-situ-hybridization, other molecular methods)
    CopyrightThis artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.
    A valid code from one of the 12 code systems:
    Code System NameCode System IdCode System VersionFlexibility
     Logical Observation Identifier Names and Codes2.16.840.1.113883.6.1 DYNAMIC
     SNOMED Clinical Terms2.16.840.1.113883.6.96 DYNAMIC
     International Classification of Diseases for Oncology, version 3.2.16.840.1.113883.6.43.1 DYNAMIC
     ICD102.16.840.1.113883.6.3 DYNAMIC
     TNM Edition8 UICC2.16.840.1.113883.15.16 DYNAMIC
     TNM Edition7 UICC2.16.840.1.113883.15.6 DYNAMIC
     TNM Edition6 UICC2.16.840.1.113883.15.7 DYNAMIC
     TNM Edition5 UICC2.16.840.1.113883.15.8 DYNAMIC
     Unified Code for Units of Measure2.16.840.1.113883.6.8 DYNAMIC
     Online Mendelian Inheritance in Man 19932.16.840.1.113883.6.174 DYNAMIC
     DKG Coding scheme1.2.276.0.76.3.1.131.1.5.1 DYNAMIC
     localization codes for distant metastases1.2.276.0.76.5.401 DYNAMIC

    4.2 Problem type 1.3.6.1.4.1.19376.1.3.11.7

    Id1.3.6.1.4.1.19376.1.3.11.7Effective Date valid from 2016‑07‑11 09:52:19
    StatusKyellow.png DraftVersion Label
    NameProblemTypeDisplay NameProblem Type
    DescriptionValues for the problem under investigation
    CopyrightThis artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.
    A valid code from the code system:
    Code System NameCode System IdCode System Version
     ICD102.16.840.1.113883.6.3
    Or one of the following:
    4 Source Code Systems
    2.16.840.1.113883.6.3 - ICD10
    2.16.840.1.113883.6.96 - SNOMED Clinical Terms
    2.16.840.1.113883.5.6 - ActClass
    2.16.840.1.113883.5.1008 - Null Flavor
    Level/ TypeCodeDisplay NameCode System
    0‑L
    115597007
    Description of specimen character (procedure)
    		SNOMED Clinical Terms
    0‑L
    128462008
    Secondary malignant neoplastic disease (disorder)
    		SNOMED Clinical Terms
    0‑L
    367651003
    Malignant neoplasm of primary, secondary, or uncertain origin (morphologic abnormality)
    		SNOMED Clinical Terms
    0‑L
    SPCOBS
    specimen observation
    		ActClass
    0‑L
    3898006
    Neoplasm, benign (morphologic abnormality)
    		SNOMED Clinical Terms
    0‑L
    109355002
    Carcinoma in situ (disorder)
    		SNOMED Clinical Terms
    0‑L
    23583003
    Inflammation (morphologic abnormality)
    		SNOMED Clinical Terms
    0‑L
    33359002
    Degeneration (morphologic abnormality)
    		SNOMED Clinical Terms
    0‑L
    49601007
    Disorder of cardiovascular system (disorder)
    		SNOMED Clinical Terms
    0‑L
    ASKU
    asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.3 Container Entity Class Type 1.3.6.1.4.1.19376.1.3.11.8

    Id1.3.6.1.4.1.19376.1.3.11.8Effective Date valid from 2016‑09‑08 11:55:11
    StatusKyellow.png DraftVersion Label
    NameContainerEntityClassTypePaLMDisplay NameContainerEntityClassTypePaLM
    DescriptionTypes of Containers and their additives in Anatomic Pathology
    CopyrightThis artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.
    2 Source Code Systems
    2.16.840.1.113883.6.96 - SNOMED Clinical Terms
    1.2.840.10008.2.16.4 - DICOM Controlled Terminology
    Level/ TypeCodeDisplay NameCode System
    0‑L
    434746001
    Specimen vial (physical object)
    		SNOMED Clinical Terms
    0‑L
    434464009
    Tissue cassette (physical object)
    		SNOMED Clinical Terms
    0‑L
    434708008
    Tissue cassette for microarray (physical object)
    		SNOMED Clinical Terms
    0‑L
    433466003
    Microscope slide (physical object)
    		SNOMED Clinical Terms
    0‑S
    433453003
    Specimen container component (physical object)
    		SNOMED Clinical Terms
    1‑S
    430863003
    Tissue embedding medium (substance)
    		SNOMED Clinical Terms
    2‑L
    311731000
    Paraffin wax (substance)
    		SNOMED Clinical Terms
    2‑L
    433469005
    Frozen section embedding medium (substance)
    		SNOMED Clinical Terms
    2‑L
    61088005
    Plastic (substance)
    		SNOMED Clinical Terms
    2‑L
    10249006
    Agar (substance)
    		SNOMED Clinical Terms
    2‑L
    65345002
    Epoxy resin (substance)
    		SNOMED Clinical Terms
    2‑L
    427811002
    Polymethyl methacrylate (substance)
    		SNOMED Clinical Terms
    1‑L
    433472003
    Microscope slide coverslip (physical object)
    		SNOMED Clinical Terms
    1‑L
    430862008
    Microscope slide mounting medium (substance)
    		SNOMED Clinical Terms
    0‑S
    CID8101
    Container type
    		DICOM Controlled Terminology
    1‑L
    A-01024
    Specimen vial
    		DICOM Controlled Terminology
    1‑L
    A-0101B
    Microscope slide
    		DICOM Controlled Terminology
    1‑L
    A-01023
    Specimen container
    		DICOM Controlled Terminology
    1‑L
    A-01021
    Electron microscopy grid
    		DICOM Controlled Terminology
    1‑L
    A-01025
    Specimen well
    		DICOM Controlled Terminology
    0‑S
    CID8114
    Fixatives
    		DICOM Controlled Terminology
    0‑S
    CID8102
    Container Component Types
    		DICOM Controlled Terminology
    0‑S
    CID8115
    Specimen Embedding Media
    		DICOM Controlled Terminology
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.4 Procedure (target) site 1.3.6.1.4.1.19376.1.3.11.9

    Id1.3.6.1.4.1.19376.1.3.11.9Effective Date valid from 2016‑06‑01 18:46:15
    StatusKyellow.png DraftVersion Label
    NameProcedureSiteDisplay NameProcedure Site
    DescriptionTarget sites of specimen processing procedures
    CopyrightThis artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.
    2 Source Code Systems
    2.16.840.1.113883.6.96 - SNOMED Clinical Terms
    1.2.840.10008.2.16.4 - DICOM Controlled Terminology
    Level/ TypeCodeDisplay NameCode SystemDescription
    0‑L
    309050000
    Body substance sample
    		SNOMED Clinical Termsall children of "Body substance sample"
    0‑L
    309051001
    Body fluid sample
    		SNOMED Clinical Terms
    0‑S
    430856003
    Tissue section (specimen)
    		SNOMED Clinical Terms
    1‑L
    441652008
    Formalin-fixed paraffin-embedded tissue specimen
    		SNOMED Clinical Terms
    1‑L
    16214131000119104
    Frozen tissue section sample (specimen)
    		SNOMED Clinical Terms
    0‑S
    CID8103
    Anatomic Pathology Specimen Types
    		DICOM Controlled Terminology
    1‑L
    G-843A
    Gross specimen
    		DICOM Controlled Terminology
    1‑L
    G-843B
    Core sample of tissue block
    		DICOM Controlled Terminology
    1‑L
    G-843C
    Tissue spot
    		DICOM Controlled Terminology
    1‑L
    G-803C
    Smear sample
    		DICOM Controlled Terminology
    1‑L
    T-1A404
    Touch preparation cytologic material
    		DICOM Controlled Terminology
    1‑L
    T-1A403
    Liquid based cytologic material
    		DICOM Controlled Terminology
    1‑L
    G-8003
    Aspirate
    		DICOM Controlled Terminology
    0‑L
    48469005
    Cytologic material (specimen)
    		SNOMED Clinical Terms
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.5 Specimen collection and processing 1.3.6.1.4.1.19376.1.3.11.10

    Id1.3.6.1.4.1.19376.1.3.11.10Effective Date valid from 2016‑05‑31 15:09:59
    StatusKyellow.png DraftVersion Label
    NameSpecimenCollectionAndProcessingDisplay NameSpecimen Collection and Processing
    DescriptionMixed Value set for Specimen collection and Processing
    CopyrightThis artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.
    5 Source Code Systems
    2.16.840.1.113883.5.6 - ActClass
    2.16.840.1.113883.6.96 - SNOMED Clinical Terms
    1.2.276.0.76.5.464
    1.2.840.10008.2.16.4 - DICOM Controlled Terminology
    2.16.840.1.113883.6.4 - International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)
    Level/ TypeCodeDisplay NameCode SystemDesignations
    0‑S
    SPECCOLLECT
    Specimen collection
    		ActClass
    1‑S
    17636008
    Specimen collection (procedure)
    		SNOMED Clinical Terms
    2‑L
    48635004
    Fine needle biopsy (procedure)
    		SNOMED Clinical Terms
    2‑S
    86273004
    Biopsy (procedure)
    		SNOMED Clinical Terms
    3‑L
    439336003
    Brush biopsy (procedure)
    		SNOMED Clinical Terms
    3‑L
    53767003
    Endoscopic biopsy (procedure)
    		SNOMED Clinical Terms
    3‑L
    8889005
    Excisional biopsy (procedure)
    		SNOMED Clinical Terms
    3‑S
    277590007
    Imaging guided biopsy (procedure)
    		SNOMED Clinical Terms
    4‑L
    442787002
    Fine needle aspiration biopsy using imaging guidance (procedure)
    		SNOMED Clinical Terms
    4‑L
    277592004
    Magnetic resonance imaging guided biopsy (procedure)
    		SNOMED Clinical Terms
    4‑L
    277667006
    Ultrasound guided biopsy (procedure)
    		SNOMED Clinical Terms
    4‑L
    277666002
    X-ray guided biopsy (procedure)
    		SNOMED Clinical Terms
    3‑L
    45681003
    Staging operation involving incision, exploration and biopsy (procedure)
    		SNOMED Clinical Terms
    3‑L
    70871006
    Incisional biopsy (procedure)
    		SNOMED Clinical Terms
    3‑L
    129249002
    Needle biopsy (procedure)
    		SNOMED Clinical Terms
    3‑L
    119283008
    Open biopsy (procedure)
    		SNOMED Clinical Terms
    3‑L
    68660007
    Punch biopsy (procedure)
    		SNOMED Clinical Terms
    3‑L
    72342005
    Shave biopsy (procedure)
    		SNOMED Clinical Terms
    3‑L
    274330002
    Surgical biopsy (procedure)
    		SNOMED Clinical Terms
    3‑L
    50590007
    Trephine biopsy (procedure)
    		SNOMED Clinical Terms
    2‑S
    65801008
    Excision (procedure)
    		SNOMED Clinical Terms
    3‑L
    81723002
    Amputation (procedure)
    		SNOMED Clinical Terms
    3‑L
    86743009
    Local excision (procedure)
    		SNOMED Clinical Terms
    3‑L
    125571002
    Lobectomy (procedure)
    		SNOMED Clinical Terms
    3‑L
    26007001
    Hemi-excision (procedure)
    		SNOMED Clinical Terms
    3‑L
    38829003
    Partial excision (procedure)
    		SNOMED Clinical Terms
    3‑L
    89540006
    Segmental excision and ligation (procedure)
    		SNOMED Clinical Terms
    3‑L
    65854006
    Reexcision (procedure)
    		SNOMED Clinical Terms
    3‑S
    62141006
    Radical excision (procedure)
    		SNOMED Clinical Terms
    4‑L
    88088007
    Radical excision with lymph node dissection (procedure)
    		SNOMED Clinical Terms
    3‑L
    79095000
    Complete excision of organ (procedure)
    		SNOMED Clinical Terms
    3‑L
    370612006
    Excision of neoplasm (procedure)
    		SNOMED Clinical Terms
    3‑L
    20418004
    Wedge resection (procedure)
    		SNOMED Clinical Terms
    2‑L
    56757003
    Scraping (procedure)
    		SNOMED Clinical Terms
    1‑L
    1-40...1-49
    Biopsies without incision
    		1.2.276.0.76.5.464
    1‑L
    1-50...1-58
    Biopsies with incision
    		1.2.276.0.76.5.464
    1‑L
    5-01...5-09
    Surgical measures
    		1.2.276.0.76.5.464
    1‑L
    1-10...1-99
    Diagnostic measures
    		1.2.276.0.76.5.464
    1‑S
    CID8109
    all children of Specimen Collection Procedure
    		DICOM Controlled Terminology
    1‑S
    00...0Y
    all children of 0
    		International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)
    0‑S
    SPCTRT
    Specimen treatment
    		ActClass
    1‑S
    CID8110
    all children of Specimen Sampling Procedures
    		DICOM Controlled Terminology
    1‑S
    CID8111
    all children of Specimen Preparation Procedure
    		DICOM Controlled Terminology
    1‑S
    CID8112
    all children of Specimen Stains
    		DICOM Controlled Terminology
    1‑S
    CID8113
    all children of Specimen Preparation Steps
    		DICOM Controlled Terminology
    1‑S
    CID8114
    all children of Specimen Fixatives
    		DICOM Controlled Terminology
    1‑S
    9265001
    Specimen processing (procedure)
    		SNOMED Clinical Terms
    2‑L
    430854000
    Touch preparation of specimen (procedure)
    		SNOMED Clinical Terms
    2‑L
    448938001
    Preparation of smear (procedure)
    		SNOMED Clinical Terms
    2‑L
    77896007
    Cytopathology procedure, cell block and smear preparation (procedure)
    		SNOMED Clinical Terms
    2‑L
    4064007
    Specimen aliquoting (procedure)
    		SNOMED Clinical Terms
    2‑L
    8378006
    Trimming (procedure)
    		SNOMED Clinical Terms
    2‑L
    73373003
    Specimen centrifugation (procedure)
    		SNOMED Clinical Terms
    2‑L
    27872000
    Specimen freezing (procedure)
    		SNOMED Clinical Terms
    2‑L
    104166004
    Nucleic acid molecular isolation or extraction method (procedure)
    		SNOMED Clinical Terms
    2‑S
    13283003
    Tissue processing technique (procedure)
    		SNOMED Clinical Terms
    3‑L
    27204007
    Tissue frozen section technique, complete (procedure)
    		SNOMED Clinical Terms
    3‑L
    40923002
    Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)
    		SNOMED Clinical Terms
    4‑L
    434472006
    Sectioning of tissue block (procedure)
    		SNOMED Clinical Terms
    4‑L
    434475008
    Step sectioning of tissue block (procedure)
    		SNOMED Clinical Terms
    4‑L
    434474007
    Surface recutting of tissue block (procedure)
    		SNOMED Clinical Terms
    4‑L
    434479002
    Core sampling of tissue block (procedure)
    		SNOMED Clinical Terms
    4‑L
    433454009
    Microdissection of tissue specimen using laser (procedure)
    		SNOMED Clinical Terms
    4‑L
    702941008
    Paraffin embedding (qualifier value)
    		SNOMED Clinical Terms
    2‑S
    127790008
    Staining method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406792001
    Acid phosphatase stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406901007
    Neutrophil alkaline phosphatase stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406902000
    New fuchsin stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406903005
    Nile blue stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406904004
    Nitrazine yellow stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    117229004
    Nonspecific esterase stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406905003
    Nuclear fast red stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406906002
    Orange G stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406907006
    Orange II stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406908001
    Page blue 83 stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406909009
    Page blue G-90 stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406910004
    Patent blue V sodium salt stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406911000
    Permethrin stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406912007
    Phloxin B stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406913002
    Ponceau 3R stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406914008
    Ponceau S stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406915009
    Ponceau xylidine stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406916005
    Pontamine sky blue 5BX stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406900008
    Naphthol yellow S stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406899003
    Naphthol green B stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406898006
    Naphthalene black 12B stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    117306005
    Lawson-Van Gieson stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406875003
    Leishman stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406876002
    Light green SF stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406877006
    Lissamine fast red B stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406878001
    Lissamine fast yellow stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406880007
    Lissamine rhodamine stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    398507009
    Malachite green stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    117218003
    Mallory bleach stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406890004
    Martius yellow stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406891000
    Meldola blue stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406892007
    Metanil yellow stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406893002
    Methyl blue stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406894008
    Methyl orange stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406895009
    Methyl red stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406896005
    Methylene blue stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406897001
    Methylene violet stain (Bernthsen) method (procedure)
    		SNOMED Clinical Terms
    3‑L
    37926009
    Microbial stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406917001
    Pontamine sky blue 6BX stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406918006
    Procion brilliant blue MRS stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    117326009
    Quinacrine fluorescent stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406936006
    Sudan blue stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406937002
    Sunset yellow FCF stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    117031001
    Supravital stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406938007
    Tartrazine stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406939004
    Thioflavine T stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406940002
    Thionine stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406941003
    Titan yellow stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406942005
    Tropaeolin O stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406943000
    Tropaeolin OO stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406944006
    Trypan blue stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406945007
    Vital new red stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    104249006
    Vital stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406946008
    Water soluble aniline blue stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406948009
    Water soluble anthracene brown stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406947004
    Water soluble nigrosine stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406949001
    Waxoline blue stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406950001
    Xylene cyanol FF stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406934009
    Sudan black stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406935005
    Sudan black B stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    117030000
    Sudan IV stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406919003
    Romanowsky stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406920009
    Rose bengal stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406921008
    Rosolic acid sodium salt stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406922001
    Saffron stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    117330007
    Schmorl stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    117041003
    Silver stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406924000
    Sirius red F3B stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406925004
    Solochrome azurine (BS) stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406926003
    Solochrome black 6B stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406927007
    Solochrome cyanine R stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406928002
    Solochrome dark blue stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406929005
    Soluble berlin blue stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406930000
    Spirit soluble aniline blue stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406931001
    Spirit soluble eosin stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406932008
    Spore stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406933003
    Sudan II stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    117029005
    Sudan III stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406874004
    Lacmoid stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406873005
    Kenacid blue R stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406818007
    Bismark brown Y stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406819004
    Blue shade eosin stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406820005
    Brazilin stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406821009
    Brilliant cresyl blue stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406822002
    Brilliant crocein stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406823007
    Brilliant orange stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406824001
    Brilliant yellow stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    77281003
    Calcofluor white stain (procedure)
    		SNOMED Clinical Terms
    3‑L
    406825000
    Carminic acid stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406826004
    Carmoisine A stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406827008
    Celestine blue B stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406828003
    Chloroacetate esterase stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406830001
    Chromotrope 2R stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406831002
    Chrysoidine R stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406832009
    Chrysoidine Y stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406833004
    Cochineal stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    117055006
    Congo red stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406817002
    Bismark brown R stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406816006
    Biebrich scarlet stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406815005
    Beta-glucuronidase stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406793006
    Albert's stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    117036006
    Alcian blue stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406794000
    Alcohol soluble nigrosine stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406795004
    Alizarin blue S stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406796003
    Alizarin cyanine green stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406797007
    Alizarin red S stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406798002
    Alizarin yellow GG stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406799005
    Alizarin yellow R stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406800009
    Auramine stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406801008
    Azo black stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406802001
    Azocarmine G (GX) stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406803006
    Azophloxin stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406804000
    Azorubin S stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406811001
    Azure A stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406812008
    Azure B stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406813003
    Azure C stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406814009
    Benzo fast scarlet stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406835006
    Crystal ponceau stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406836007
    Curcumin stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    117298004
    Cytopathology staining method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406857004
    Flagellar stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406858009
    Fluorescent stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406863008
    Fuchsin acid stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    117047004
    Fuchsin basic stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    20543007
    Fungus stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406864002
    Gallocyanine stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    422329009
    Hall's bilirubin stain (procedure)
    		SNOMED Clinical Terms
    3‑L
    406865001
    Hematein stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    108256005
    Hematology staining procedure (procedure)
    		SNOMED Clinical Terms
    3‑L
    406867009
    Immunofluorescent stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406868004
    Indigo carmine stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406869007
    Indophenol from naphthol stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406870008
    Insoluble berlin blue stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406871007
    Janus green B stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406872000
    Jenner-Giemsa stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406856008
    Field's stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406855007
    Feulgen reaction stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406854006
    Fat red 7B stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406837003
    Diamond black stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406838008
    Durazol red stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406839000
    Erie garnet stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406840003
    Eriochrome blue black SE stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406841004
    Erythrosin B stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406842006
    Erythrosin Y stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406843001
    Evans blue stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406844007
    Fast blue B salt stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406845008
    Fast blue BB salt stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406846009
    Fast blue RR salt stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406847000
    Fast garnet GBC salt stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406848005
    Fast green FCF stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406849002
    Fast red B salt stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406850002
    Fast red ITR stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406851003
    Fast red TR salt stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406852005
    Fast sulfon black F stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406853000
    Fast violet B salt stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    406979008
    Ziehl-Neelsen stain method (procedure)
    		SNOMED Clinical Terms
    3‑S
    104210008
    Hematoxylin and eosin stain method (procedure)
    		SNOMED Clinical Terms
    4‑L
    117239005
    Harris regressive hematoxylin and eosin stain method (procedure)
    		SNOMED Clinical Terms
    4‑L
    117240007
    Mayers progressive hematoxylin and eosin stain method (procedure)
    		SNOMED Clinical Terms
    3‑L
    80246006
    Special stain, blood or bone marrow, explain by report (procedure)
    		SNOMED Clinical Terms
    3‑L
    117617002
    Immunohistochemistry procedure (procedure)
    		SNOMED Clinical Terms
    3‑L
    384715000
    Nucleic acid hybridization procedure (procedure)
    		SNOMED Clinical Terms
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    4.6 UICC/AJCC stage 1.3.6.1.4.1.19376.1.3.11.18

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    stage 0a
    		TNM Edition7 UICCin C67 only
    1‑L
    0is
    stage 0is
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    		TNM Edition7 UICCorgan dependent<br clear="none"/>
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    		TNM Edition7 UICCorgan dependent
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    		TNM Edition7 UICCorgan dependent<br clear="none"/>
    1‑L
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    stage IC
    		TNM Edition7 UICCorgan dependent<br clear="none"/>
    1‑L
    IS
    stage IS
    		TNM Edition7 UICCin C62 only
    0‑S
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    stage II
    		TNM Edition7 UICCorgan dependent<br clear="none"/>
    2‑L
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    stage IIA
    		TNM Edition7 UICCorgan dependent<br clear="none"/> <br clear="none"/>
    2‑L
    IIA1
    stage IIA1
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    		TNM Edition7 UICCorgan dependent<br clear="none"/>
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    		TNM Edition7 UICCorgan dependent<br clear="none"/>
    1‑L
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    stage IIC
    		TNM Edition7 UICCorgan dependent<br clear="none"/> <br clear="none"/>
    0‑S
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    stage III
    		TNM Edition7 UICCorgan dependent<br clear="none"/>
    1‑L
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    stage IIIA
    		TNM Edition7 UICCorgan dependent<br clear="none"/>
    1‑L
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    stage IIIB
    		TNM Edition7 UICCorgan dependent<br clear="none"/> <br clear="none"/>
    1‑L
    IIIC
    stage IIIC
    		TNM Edition7 UICCorgan dependent<br clear="none"/>
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    stage IV
    		TNM Edition7 UICCeach T, each N, M1
    1‑L
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    stage IVA
    		TNM Edition7 UICCorgan dependent<br clear="none"/>
    1‑L
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    stage IVB
    		TNM Edition7 UICCorgan dependent<br clear="none"/>
    1‑L
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    stage IVC
    		TNM Edition7 UICCorgan dependent<br clear="none"/>
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    4.7 UICC/AJCC T category 1.3.6.1.4.1.19376.1.3.11.15

    Id1.3.6.1.4.1.19376.1.3.11.15Effective Date valid from 2015‑11‑11 14:05:36
    StatusKyellow.png DraftVersion Label
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    2 Source Code Systems
    2.16.840.1.113883.15.6 - TNM Edition7 UICC
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    Ta
    		TNM Edition7 UICC
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    		TNM Edition7 UICC
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    Tis(Paget)
    Tis(Paget)
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    Tis(pu)
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    		TNM Edition7 UICC
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    Tis(pd)
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    T0
    		TNM Edition7 UICC
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    T1
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    		TNM Edition7 UICC
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    T1mi
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    		TNM Edition7 UICC
    1‑L
    T1a
    T1a
    		TNM Edition7 UICC
    2‑L
    T1a1
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    		TNM Edition7 UICC
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    		TNM Edition7 UICC
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    		TNM Edition7 UICC
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    T1b1
    		TNM Edition7 UICC
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    		TNM Edition7 UICC
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    T1c
    T1c
    		TNM Edition7 UICC
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    T1d
    T1d
    		TNM Edition7 UICC
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    T2
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    		TNM Edition7 UICC
    1‑L
    T2a
    T2a
    		TNM Edition7 UICC
    2‑L
    T2a1
    T2a1
    		TNM Edition7 UICC
    2‑L
    T2a2
    T2a2
    		TNM Edition7 UICC
    1‑L
    T2b
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    		TNM Edition7 UICC
    1‑L
    T2c
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    		TNM Edition7 UICC
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    		TNM Edition7 UICC
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    		TNM Edition7 UICC
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    		TNM Edition7 UICC
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    		TNM Edition7 UICC
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    T4c
    		TNM Edition7 UICC
    1‑L
    T4d
    T4d
    		TNM Edition7 UICC
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    T4e
    		TNM Edition7 UICC
    0‑L
    Tx
    TX
    		TNM Edition7 UICC
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    ASKU
    Asked, but unknown
    		Null Flavor
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    4.8 UICC/AJCC T category (SCT) 1.3.6.1.4.1.19376.1.3.11.12

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    DescriptionT-Value from UICC classification
    CopyrightThis artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.
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    Tumor stage Ta (tumor staging)
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    		SNOMED Clinical Terms
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    313145008
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    T0 category (finding)
    		SNOMED Clinical Terms
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    23351008
    T1 category (finding)
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    313108002
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    Tumor stage T2c (finding)
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    T3 category (finding)
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    1‑L
    261654001
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    261655000
    Tumor stage T3b (finding)
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    261656004
    Tumor stage T3bi (finding)
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    2‑L
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    Tumor stage T3bii (finding)
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    261658003
    Tumor stage T3c (finding)
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    261659006
    Tumor stage T4a (finding)
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    Tumor stage T4b (finding)
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    		SNOMED Clinical Terms
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    TX category (finding)
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    Asked but unknown
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    4.9 UICC/AJCC N category 1.3.6.1.4.1.19376.1.3.11.16

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    2.16.840.1.113883.15.6 - TNM Edition7 UICC
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    N1b
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    		TNM Edition7 UICC
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    		TNM Edition7 UICC
    1‑L
    N3c
    N3c
    		TNM Edition7 UICC
    0‑L
    NX
    Nx
    		TNM Edition7 UICC
    0‑L
    ASKU
    Asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.10 UICC/AJCC N category (SCT) 1.3.6.1.4.1.19376.1.3.11.13

    Id1.3.6.1.4.1.19376.1.3.11.13Effective Date valid from 2014‑10‑27 14:47:35
    StatusKyellow.png DraftVersion Label
    NameUICC_N_valuesDisplay NameUICC N category (SCT)
    DescriptionN-Value from UICC classification
    CopyrightThis artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.
    2 Source Code Systems
    2.16.840.1.113883.6.96 - SNOMED Clinical Terms
    2.16.840.1.113883.5.1008 - Null Flavor
    Level/ TypeCodeDisplay NameCode System
    0‑L
    62455006
    N0 category (finding)
    		SNOMED Clinical Terms
    0‑L
    53623008
    N1 category (finding)
    		SNOMED Clinical Terms
    1‑L
    277672002
    Node stage N1a (finding)
    		SNOMED Clinical Terms
    1‑L
    277674001
    Node stage N1b (finding)
    		SNOMED Clinical Terms
    2‑L
    277772008
    Node stage N1bi (finding)
    		SNOMED Clinical Terms
    2‑L
    277776006
    Node stage N1bii (finding)
    		SNOMED Clinical Terms
    2‑L
    277777002
    Node stage N1biii (finding)
    		SNOMED Clinical Terms
    2‑L
    277778007
    Node stage N1biv (finding)
    		SNOMED Clinical Terms
    1‑L
    369996002
    N1c: >7 nodes involved (finding)
    		SNOMED Clinical Terms
    0‑L
    46059003
    N2 category (finding)
    		SNOMED Clinical Terms
    1‑L
    261967001
    Node stage N2a (finding)
    		SNOMED Clinical Terms
    1‑L
    261968006
    Node stage N2b (finding)
    		SNOMED Clinical Terms
    1‑L
    261969003
    Node stage N2c (finding)
    		SNOMED Clinical Terms
    0‑L
    5856006
    N3 category (finding)
    		SNOMED Clinical Terms
    1‑L
    370012005
    N3a: > 6 cm in dimension (finding)
    		SNOMED Clinical Terms
    1‑L
    370013000
    N3b: extension to supraclavicular fossa (finding)
    		SNOMED Clinical Terms
    0‑L
    79420006
    NX category (finding)
    		SNOMED Clinical Terms
    0‑L
    ASKU
    Asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.11 UICC/AJCC M category 1.3.6.1.4.1.19376.1.3.11.17

    Id1.3.6.1.4.1.19376.1.3.11.17Effective Date valid from 2015‑11‑11 15:53:15
    StatusKyellow.png DraftVersion Label
    NameUICC-m-valuesDisplay NameUICC M category (7ed)
    CopyrightThis artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.
    2 Source Code Systems
    2.16.840.1.113883.15.6 - TNM Edition7 UICC
    2.16.840.1.113883.5.1008 - Null Flavor
    Level/ TypeCodeDisplay NameCode System
    0‑L
    M0
    M0
    		TNM Edition7 UICC
    0‑L
    M1
    M1
    		TNM Edition7 UICC
    1‑L
    M1mi
    M1(mi)
    		TNM Edition7 UICC
    1‑L
    M1a
    M1a
    		TNM Edition7 UICC
    1‑L
    M1b
    M1b
    		TNM Edition7 UICC
    1‑L
    M1c
    M1c
    		TNM Edition7 UICC
    1‑L
    M1d
    M1d
    		TNM Edition7 UICC
    1‑L
    M1e
    M1e
    		TNM Edition7 UICC
    1‑L
    M1cy
    M1(cy)
    		TNM Edition7 UICC
    0‑L
    MX
    MX
    		TNM Edition7 UICC
    0‑L
    ASKU
    Asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.12 UICC/AJCC M category (SCT) 1.3.6.1.4.1.19376.1.3.11.14

    Id1.3.6.1.4.1.19376.1.3.11.14Effective Date valid from 2014‑05‑13 16:11:15
    StatusKyellow.png DraftVersion Label
    NameUICC-m-valueDisplay NameUICC M category (SCT)
    DescriptionM-Value from UICC classification
    CopyrightThis artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.
    2 Source Code Systems
    2.16.840.1.113883.6.96 - SNOMED Clinical Terms
    2.16.840.1.113883.5.1008 - Null Flavor
    Level/ TypeCodeDisplay NameCode System
    0‑L
    30893008
    M0 category (finding)
    		SNOMED Clinical Terms
    0‑L
    55440008
    M1 category (finding)
    		SNOMED Clinical Terms
    1‑L
    261927002
    Metastasis stage M1a (finding)
    		SNOMED Clinical Terms
    1‑L
    261928007
    Metastasis stage M1b (finding)
    		SNOMED Clinical Terms
    1‑L
    261929004
    Metastasis stage M1c (finding)
    		SNOMED Clinical Terms
    0‑L
    27167007
    MX category (finding)
    		SNOMED Clinical Terms
    0‑L
    ASKU
    Asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.13 UICC/AJCC C-Factor 1.3.6.1.4.1.19376.1.3.11.19

    Id1.3.6.1.4.1.19376.1.3.11.19Effective Date valid from 2015‑11‑13 13:56:23
    StatusKyellow.png DraftVersion Label
    Nameuicc-c-factor-tnmDisplay NameUICC C-Factor
    DescriptionQualifier for any TNM category coding the certainty of classification by the methods used
    Source Code System
    2.16.840.1.113883.15.6 - TNM Edition7 UICC
    Level/ TypeCodeDisplay NameCode System
    0‑L
    C1
    C1
    		TNM Edition7 UICC
    0‑L
    C2
    C2
    		TNM Edition7 UICC
    0‑L
    C3
    C3
    		TNM Edition7 UICC
    0‑L
    C4
    C4
    		TNM Edition7 UICC
    0‑L
    C5
    C5
    		TNM Edition7 UICC
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.14 UICC/AJCC C-Factor (SCT) 1.3.6.1.4.1.19376.1.3.11.20

    Id1.3.6.1.4.1.19376.1.3.11.20Effective Date valid from 2015‑06‑22 15:47:55
    StatusKyellow.png DraftVersion Label
    Nameuicc-c-factorDisplay NameUICC C-Factor (SCT)
    DescriptionQualifier for any TNM category coding the certainty of classification by the methods used
    CopyrightThis artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.
    Source Code System
    2.16.840.1.113883.6.96 - SNOMED Clinical Terms
    Level/ TypeCodeDisplay NameCode System
    0‑L
    84068000
    C1 - TNM certainty factor
    		SNOMED Clinical Terms
    0‑L
    76321005
    C2 - TNM certainty factor
    		SNOMED Clinical Terms
    0‑L
    44756004
    C3 - TNM certainty factor
    		SNOMED Clinical Terms
    0‑L
    75800005
    C4 - TNM certainty factor
    		SNOMED Clinical Terms
    0‑L
    59397002
    C5 - TNM certainty factor
    		SNOMED Clinical Terms
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.15 UICC/AJCC Residual tumor (R) classification 1.3.6.1.4.1.19376.1.3.11.21

    Id1.3.6.1.4.1.19376.1.3.11.21Effective Date valid from 2015‑06‑25 11:23:51
    StatusKyellow.png DraftVersion Label
    NameUICC-R-statusDisplay NameUICC Residual tumor (R) classification
    DescriptionValue set for Residual tumor state with values for extended R-Klassifikation (TNM Suppl. 4th ed.)
    CopyrightThis artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.
    5 Source Code Systems
    2.16.840.1.113883.6.96 - SNOMED Clinical Terms
    2.16.840.1.113883.15.16 - TNM Edition8 UICC
    2.16.840.1.113883.15.6 - TNM Edition7 UICC
    1.2.276.0.76.3.1.131.1.5.120
    2.16.840.1.113883.5.1008 - Null Flavor
    Level/ TypeCodeDisplay NameCode SystemDescription
    0‑L
    258254000
    Residual tumor stage R0 (finding)
    		SNOMED Clinical Terms
    1‑L
    415675004
    Surgical circumferential margin is closest uninvolved margin to malignant neoplasm (finding)
    		SNOMED Clinical TermsNo residual tumor: R0 > 1mm CRM negative
    0‑L
    278271003
    Residual tumor stage R1 (finding)
    		SNOMED Clinical Terms
    1‑L
    384620009
    Surgical circumferential margin involved by malignant neoplasm (tumor present 0-1 mm from circumferential resection margin) (finding)
    		SNOMED Clinical Terms
    0‑L
    278272005
    Residual tumor stage R2 (finding)
    		SNOMED Clinical Terms
    0‑L
    258253006
    Residual tumor stage RX (finding)
    		SNOMED Clinical Terms
    0‑L
    RX
    RX
    		TNM Edition8 UICC
    0‑L
    R0>1mm
    R0 > 1mm
    		TNM Edition7 UICC
    0‑L
    R0<1mm
    R0 < 1mm
    		TNM Edition7 UICC
    0‑L
    R1
    R1
    		TNM Edition8 UICC
    1‑L
    R1-dir
    R1-dir
    		TNM Edition7 UICC
    1‑L
    R1(is)
    R1(is)
    		1.2.276.0.76.3.1.131.1.5.120
    1‑L
    R1(cy)
    R1(cy)
    		1.2.276.0.76.3.1.131.1.5.120
    0‑L
    R2
    R2
    		TNM Edition8 UICC
    1‑L
    R2a
    R2a
    		TNM Edition7 UICC
    1‑L
    R2b
    R2b
    		TNM Edition7 UICC
    1‑L
    R2c
    R2c
    		TNM Edition7 UICC
    0‑L
    CRM+
    CRM positive
    		TNM Edition7 UICC
    0‑L
    CRM-
    CRM negative
    		TNM Edition7 UICC
    0‑L
    ASKU
    Asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.16 UICC/AJCC clinical/pathological 1.3.6.1.4.1.19376.1.3.11.22

    Id1.3.6.1.4.1.19376.1.3.11.22Effective Date valid from 2015‑11‑04 15:52:34
    StatusKyellow.png DraftVersion Label
    NameUICC-clinical-pathologicalDisplay NameUICC clinical/pathological
    DescriptionQualifiers for each TNM category classifying the observation method and the time frame of observation in relation to treatment
    3 Source Code Systems
    2.16.840.1.113883.15.16 - TNM Edition8 UICC
    1.2.276.0.76.11.9 - hl7de-valueset-9
    2.16.840.1.113883.5.1008 - Null Flavor
    Level/ TypeCodeDisplay NameCode SystemDescription
    0‑L
    p
    p
    		TNM Edition8 UICCThe pathological assessment of the primary tumor entails a resection of the primary tumor or a biopsy adequate to evaluate the highest T category. The pathological assessment of the regional lymph nodes entails a removal of lymph nodes adequate to validate the absence of regional lymph node metastasis or sufficient to evaluate the highest pN category. The pathological assessment of distant metastasis entails microscopic examination.
    0‑L
    c
    c
    		TNM Edition8 UICCThe clinical classification is based on evidence acquired before treatment
    1‑L
    u
    u
    		hl7de-valueset-9The clinical classification is based on ultrasound evidence acquired before treatment
    1‑L
    ct
    ct
    		hl7de-valueset-9The clinical classification is based on CT imaging evidence acquired before treatment
    1‑L
    mr
    mr
    		hl7de-valueset-9The clinical classification is based on magnetic resonance imaging evidence acquired before treatment
    0‑L
    ASKU
    Asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.17 UICC/AJCC Venous Invasion 1.3.6.1.4.1.19376.1.3.11.23

    Id1.3.6.1.4.1.19376.1.3.11.23Effective Date valid from 2015‑11‑04 16:17:55
    StatusKyellow.png DraftVersion Label
    NameUICC-vene-invasionDisplay NameUICC Venous Invasion
    DescriptionObservation for tumor spread coding the degree of venous invasion
    2 Source Code Systems
    2.16.840.1.113883.15.16 - TNM Edition8 UICC
    2.16.840.1.113883.5.1008 - Null Flavor
    Level/ TypeCodeDisplay NameCode System
    0‑L
    V0
    V0
    		TNM Edition8 UICC
    0‑L
    V1
    V1
    		TNM Edition8 UICC
    0‑L
    V2
    V2
    		TNM Edition8 UICC
    0‑L
    VX
    VX
    		TNM Edition8 UICC
    0‑L
    ASKU
    Asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.18 UICC/AJCC Lymphatic Invasion 1.3.6.1.4.1.19376.1.3.11.24

    Id1.3.6.1.4.1.19376.1.3.11.24Effective Date valid from 2015‑11‑04 16:19:20
    StatusKyellow.png DraftVersion Label
    NameUICC-lymphatic-invasionDisplay NameUICC Lymphatic Invasion
    DescriptionObservation for tumor spread coding the degree of lymphatic invasion
    2 Source Code Systems
    2.16.840.1.113883.15.16 - TNM Edition8 UICC
    2.16.840.1.113883.5.1008 - Null Flavor
    Level/ TypeCodeDisplay NameCode System
    0‑L
    L0
    L0
    		TNM Edition8 UICC
    0‑L
    L1
    L1
    		TNM Edition8 UICC
    0‑L
    LX
    LX
    		TNM Edition8 UICC
    0‑L
    ASKU
    Asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.19 UICC/AJCC Perineurial Invasion 1.3.6.1.4.1.19376.1.3.11.25

    Id1.3.6.1.4.1.19376.1.3.11.25Effective Date valid from 2015‑11‑04 16:20:42
    StatusKyellow.png DraftVersion Label
    NameUICC-perineural-invasionDisplay NameUICC Perineural Invasion
    Description 
       Observation for tumor spread coding the degree of perineural (lymphatic nerve sheet) invasion


    2 Source Code Systems
    2.16.840.1.113883.15.16 - TNM Edition8 UICC
    2.16.840.1.113883.5.1008 - Null Flavor
    Level/ TypeCodeDisplay NameCode SystemDescription
    0‑L
    Pn0
    Pn0
    		TNM Edition8 UICCno perineural invasion
    0‑L
    Pn1
    Pn1
    		TNM Edition8 UICCPerineural invasion
    0‑L
    PnX
    PnX
    		TNM Edition8 UICCunknown
    0‑L
    ASKU
    Asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.20 UICC/AJCC Mucosa 1.3.6.1.4.1.19376.1.3.11.26

    Id1.3.6.1.4.1.19376.1.3.11.26Effective Date valid from 2015‑11‑04 16:22:04
    StatusKyellow.png DraftVersion Label
    NameUICC-mucosaDisplay NameUICC Mucosa
    Source Code System
    1.2.276.0.76.3.1.131.1.5.1
    Level/ TypeCodeDisplay NameCode SystemDescription
    0‑L
    m1
    m1
    		1.2.276.0.76.3.1.131.1.5.1restricted to mucosa, 1st third
    0‑L
    m2
    m2
    		1.2.276.0.76.3.1.131.1.5.1restricted to mucosa, 2nd third
    0‑L
    m3
    m3
    		1.2.276.0.76.3.1.131.1.5.1restricted to mucosa, 3rd third
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.21 UICC/AJCC Submucosa 1.3.6.1.4.1.19376.1.3.11.27

    Id1.3.6.1.4.1.19376.1.3.11.27Effective Date valid from 2015‑11‑04 16:23:24
    StatusKyellow.png DraftVersion Label
    NameUICC-submucosaDisplay NameUICC Submucosa
    Source Code System
    1.2.276.0.76.3.1.131.1.5.1
    Level/ TypeCodeDisplay NameCode SystemDescription
    0‑L
    sm1
    sm1
    		1.2.276.0.76.3.1.131.1.5.1restricted to submucosa, 1st third
    0‑L
    sm2
    sm2
    		1.2.276.0.76.3.1.131.1.5.1restricted to submucosa, 2nd third
    0‑L
    sm3
    sm3
    		1.2.276.0.76.3.1.131.1.5.1restricted to submucosa, 3rd third
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.22 UICC/AJCC Localization of distant metastases 1.3.6.1.4.1.19376.1.3.11.28

    Id1.3.6.1.4.1.19376.1.3.11.28Effective Date valid from 2015‑11‑04 16:26:53
    StatusKyellow.png DraftVersion Label
    NameUICC-distant-metastasis-localizationDisplay NameUICC Localization of distant metastases
    DescriptionQualifier for M category coding the localization of distant metastasis in case of M1 or M2
    Source Code System
    2.16.840.1.113883.15.16 - TNM Edition8 UICC
    Level/ TypeCodeDisplay NameCode System
    0‑L
    PUL
    PUL
    		TNM Edition8 UICC
    0‑L
    OSS
    OSS
    		TNM Edition8 UICC
    0‑L
    HEP
    HEP
    		TNM Edition8 UICC
    0‑L
    BRA
    BRA
    		TNM Edition8 UICC
    0‑L
    LYM
    LYM
    		TNM Edition8 UICC
    0‑L
    OTH
    OTH
    		TNM Edition8 UICC
    0‑L
    MAR
    MAR
    		TNM Edition8 UICC
    0‑L
    PLE
    PLE
    		TNM Edition8 UICC
    0‑L
    PER
    PER
    		TNM Edition8 UICC
    0‑L
    ADR
    ADR
    		TNM Edition8 UICC
    0‑L
    SKI
    SKI
    		TNM Edition8 UICC
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.23 UICC/AJCC Grade 3 tiered 1.3.6.1.4.1.19376.1.3.11.29

    Id1.3.6.1.4.1.19376.1.3.11.29Effective Date valid from 2015‑11‑13 19:36:21
    StatusKyellow.png DraftVersion Label
    NameUICCgradeDisplay NameUICC Grade 3 tiered
    DescriptionCoding of the grade of differentiation (malignancy) of tumors, coded by a four-, three-, or two-tiered grading system, often using the score of a special grading system for certain tumor types
    2 Source Code Systems
    2.16.840.1.113883.15.16 - TNM Edition8 UICC
    2.16.840.1.113883.5.1008 - Null Flavor
    Level/ TypeCodeDisplay NameCode SystemDescription
    0‑L
    1
    G1
    		TNM Edition8 UICCgrade 1, well (highly) differentiated
    0‑L
    2
    G2
    		TNM Edition8 UICCgrade 2, moderately differentiated
    0‑L
    3
    G3
    		TNM Edition8 UICCgrade 3, poorly differentiated
    0‑L
    X
    GX
    		TNM Edition8 UICCcannot be assessed
    0‑L
    ASKU
    Asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.24 UICC/AJCC Grade 2 tiered 1.3.6.1.4.1.19376.1.3.11.30

    Id1.3.6.1.4.1.19376.1.3.11.30Effective Date valid from 2015‑11‑13 19:43:09
    StatusKyellow.png DraftVersion Label
    NameUICCgrade-2Display NameUICC Grade 2 tiered
    DescriptionCoding of the grade of differentiation (malignancy) of tumors, coded by a two-tiered grading system, sometimes using the score of a special grading system for certain tumor types
    2 Source Code Systems
    2.16.840.1.113883.15.16 - TNM Edition8 UICC
    2.16.840.1.113883.5.1008 - Null Flavor
    Level/ TypeCodeDisplay NameCode SystemDescription
    0‑L
    L
    lG
    		TNM Edition8 UICClow grade, combining grade 1 and 2 (except urothelial tumors: only grade 1)
    0‑L
    H
    hG
    		TNM Edition8 UICClow grade, combining grade 3 and 4 (except urothelial tumors: grade 2 through 4)
    0‑L
    X
    X
    		TNM Edition8 UICCcannot be assessed
    0‑L
    ASKU
    Asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.25 UICC/AJCC Grade 4 tiered 1.3.6.1.4.1.19376.1.3.11.31

    Id1.3.6.1.4.1.19376.1.3.11.31Effective Date valid from 2015‑11‑13 19:46:53
    StatusKyellow.png DraftVersion Label
    NameUICCgrade-4Display NameUICC Grade 4 tiered
    DescriptionCoding of the grade of differentiation (malignancy) of tumors, coded by a four-tiered grading system, sometimes using the score of a special grading system for certain tumor types.
    3 Source Code Systems
    2.16.840.1.113883.15.16 - TNM Edition8 UICC
    1.2.276.0.76.5.336
    2.16.840.1.113883.5.1008 - Null Flavor
    Level/ TypeCodeDisplay NameCode SystemDescription
    0‑L
    1
    G1
    		TNM Edition8 UICCwell (highly) differentiated
    0‑L
    2
    G2
    		TNM Edition8 UICCmoderately differentiated
    0‑L
    3
    G3
    		TNM Edition8 UICCpoorly differentiated
    0‑L
    4
    G4
    		TNM Edition8 UICCundifferentiated resp. anaplastic
    0‑L
    X
    GX
    		TNM Edition8 UICCcannot be assessed
    0‑L
    0
    0
    		1.2.276.0.76.5.336Malignes Melanom der Konjunktiva
    0‑L
    X
    X
    		1.2.276.0.76.5.336nicht bestimmbar
    0‑L
    L
    lG
    		1.2.276.0.76.5.336Low grade (G1 oder G2)
    0‑L
    M
    mG
    		1.2.276.0.76.5.336intermediate (G2 oder G3)
    0‑L
    H
    hG
    		1.2.276.0.76.5.336high grade (G3 oder G4)
    0‑L
    B
    B
    		1.2.276.0.76.5.336Borderline-Malignität
    0‑L
    U
    U
    		1.2.276.0.76.5.336unbekannt
    0‑L
    T
    T
    		1.2.276.0.76.5.336trifft nicht zu
    0‑L
    ASKU
    Asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.26 UICC/AJCC Tumor Serum Markers 1.3.6.1.4.1.19376.1.3.11.32

    Id1.3.6.1.4.1.19376.1.3.11.32Effective Date valid from 2015‑11‑08 18:26:39
    StatusKyellow.png DraftVersion Label
    NameUICCSerumTumorMarkersDisplay NameUICC Serum Tumor Markers
    DescriptionObservation of serum levels of tumor markers coded for germ cell tumors
    2 Source Code Systems
    2.16.840.1.113883.15.16 - TNM Edition8 UICC
    2.16.840.1.113883.5.1008 - Null Flavor
    Level/ TypeCodeDisplay NameCode SystemDescription
    0‑L
    S0
    S0
    		TNM Edition8 UICCserum tumor markers within normal limits
    0‑L
    S1
    S1
    		TNM Edition8 UICCLDH < 1,5* normal limit AND ßHCG< 5000mIU/ml AND AFP <1000 ng/ml
    0‑L
    S2
    S2
    		TNM Edition8 UICCLDH 1,5 - 10* normal limit OR ßHCG 5000 - 50000 mIU/ml OR AFP 1000 - 10000 ng/ml
    0‑L
    S3
    S3
    		TNM Edition8 UICCLDH >10* normal limit OR ßHCG > 50000 mIU/ml OR AFP > 10000 ng/ml
    0‑L
    SX
    SX
    		TNM Edition8 UICCNo information about serum tumor markers
    0‑L
    ASKU
    Asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.27 ICD-O-3 Morphology 1.3.6.1.4.1.19376.1.3.11.33

    Id1.3.6.1.4.1.19376.1.3.11.33Effective Date valid from 2015‑11‑13 14:08:46
    StatusKyellow.png DraftVersion Label1st rev. (2013)
    Nameicd-o-3-mDisplay NameICD-O-3 Morphology
    DescriptionInternational classification of diseases / oncology, morphological part for typing of benign and malignant tumors. The morphology axis provides six-digit codes ranging from 8000/0 to 9989/3. The first four digits indicate the specific histological term, i.e. morphology (8000 through 9992).&#160;<span style="text-align: justify;">In developing the previous editions and the present edition of ICD-O, a particular effort was made to use the nomenclature appearing in the World Health Organization&#160;</span>

    <span style="text-align: justify;">International Histological Classification of Tumours</span>&#160;<span style="text-align: justify;">series (WHO “Blue Books”)</span> <span style="text-align: justify;">7</span>

    <span style="text-align: justify;">. This series covers all the principal sites of cancer and includes the morphology codes of ICD-O for each neoplasm.&#160;</span>All new histological classifications or modifications have been made by the WHO / IARC in so-called "Blue Books" by &#160;2011 are listed on-line: http://codes.iarc.fr/changes.php.<br clear="none"/>The fifth digit after a slash (/) is the behavior code, which indicates whether a tumor is malignant, benign, in situ, or uncertain (whether benign or malignant). <br clear="none"/>A separate, 6th, one-digit code may also be given for histologic 4-tiered grading (differentiation) or for the cell type in lymphatic neoplasia. &#160;<br clear="none"/>The fifth and the sixth digit are coded separately in value sets 1.3.6.1.4.1.19376.1.3.11.34 and 1.3.6.1.4.1.19376.1.3.11.35
    A valid code from the code system:
    Code System NameCode System IdCode System Version
     International Classification of Diseases for Oncology, version 3.2.16.840.1.113883.6.43.1
    Or one of the following:
    2 Source Code Systems
    2.16.840.1.113883.6.43.1 - International Classification of Diseases for Oncology, version 3.
    2.16.840.1.113883.5.1008 - Null Flavor
    Level/ TypeCodeCode System
    0‑L
    ASKU
    Asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.28 ICD-O-3 Behavior 1.3.6.1.4.1.19376.1.3.11.34

    Id1.3.6.1.4.1.19376.1.3.11.34Effective Date valid from 2015‑11‑13 18:54:30
    StatusKyellow.png DraftVersion Label1st rev. (2013)
    Nameicd-o-3-behaviorDisplay NameICD-O-3 Behavior
    DescriptionCoding of the behavior of a tumor, coded by the first digit after slash in ICD-O-Morphology code
    2 Source Code Systems
    2.16.840.1.113883.6.43.1 - International Classification of Diseases for Oncology, version 3.
    2.16.840.1.113883.5.1008 - Null Flavor
    Level/ TypeCodeDisplay NameCode SystemDescription
    0‑L
    0
    /0
    		International Classification of Diseases for Oncology, version 3.benign
    0‑L
    1
    /1
    		International Classification of Diseases for Oncology, version 3.borderline malignancy or uncertain malignant potential
    0‑L
    2
    /2
    		International Classification of Diseases for Oncology, version 3.noninvasiv resp. carcinoma in situ
    0‑L
    3
    /3
    		International Classification of Diseases for Oncology, version 3.invasive resp. malignant primary tumor
    0‑L
    6
    /6
    		International Classification of Diseases for Oncology, version 3.metastasis resp. secondary tumor, not used in German cancer registries
    0‑L
    9
    /9
    		International Classification of Diseases for Oncology, version 3.malignant, uncertain whether primary or secondary tumor, not used in German cancer registries
    0‑L
    ASKU
    asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.29 ICD-O-3 Differentiation 1.3.6.1.4.1.19376.1.3.11.35

    Id1.3.6.1.4.1.19376.1.3.11.35Effective Date valid from 2015‑11‑13 19:07:32
    StatusKyellow.png DraftVersion Label1st rev. (2013)
    Nameicd-o-3-differentiationDisplay NameICD-O-3 Differentiation
    DescriptionCoding the cellular differentiation of malignant tumors, either the grade of malignancy (differentiation), or the cell line differentiation, coded by the second digit after the slash in ICD-O-3 Morphology axi
    2 Source Code Systems
    2.16.840.1.113883.6.43.1 - International Classification of Diseases for Oncology, version 3.
    2.16.840.1.113883.5.1008 - Null Flavor
    Level/ TypeCodeDisplay NameCode SystemDescription
    0‑L
    1
    1
    		International Classification of Diseases for Oncology, version 3.well (highly) differentiated
    0‑L
    2
    2
    		International Classification of Diseases for Oncology, version 3.moderately differentiated
    0‑L
    3
    3
    		International Classification of Diseases for Oncology, version 3.poorly differentiated
    0‑L
    4
    4
    		International Classification of Diseases for Oncology, version 3.undifferentiated resp. anaplastic
    0‑L
    5
    5
    		International Classification of Diseases for Oncology, version 3.T-cell differentiation in lymphomas and leukemias
    0‑L
    6
    6
    		International Classification of Diseases for Oncology, version 3.B-cell differentiation, pre-B-cells, B-precursor cells in lymphomas and leukemias
    0‑L
    7
    7
    		International Classification of Diseases for Oncology, version 3.Null-cell, non-B-nonT-cell differentiation in lymphomas and leukemias
    0‑L
    8
    8
    		International Classification of Diseases for Oncology, version 3.NK (natural killer)-cell differentiation in lymphomas and leukemias
    0‑L
    9
    9
    		International Classification of Diseases for Oncology, version 3.grading not applied, not applicable, unknown; cell type not assessed or unknown
    0‑L
    ASKU
    Asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

    4.30 ICD-O-3 Topography 1.3.6.1.4.1.19376.1.3.11.36

    Id1.3.6.1.4.1.19376.1.3.11.36Effective Date valid from 2015‑11‑13 19:16:23
    StatusKyellow.png DraftVersion Label1st rev. (2013)
    Nameicd-o-3-topographyDisplay NameICD-O-3 Topography
    DescriptionInternational classification of diseases / oncology, topographical part for typing of benign and malignant tumors. The topography axis (C-axis) uses the ICD-10 classification of malignant neoplasms (except those categories which relate to secondary neoplasms and to specified morphological types of tumours) for all types of tumours, thereby providing greater site detail for non-malignant tumours than is provided in ICD-10. In contrast to ICD-10, the ICD-O includes topography for sites of haematopoietic and reticuloendothelial tumors.
    A valid code from the code system:
    Code System NameCode System IdCode System Version
     International Classification of Diseases for Oncology, version 3.2.16.840.1.113883.6.43.1
    Or one of the following:
    2 Source Code Systems
    2.16.840.1.113883.6.43.1 - International Classification of Diseases for Oncology, version 3.
    2.16.840.1.113883.5.1008 - Null Flavor
    Level/ TypeCodeCode System
    0‑L
    ASKU
    asked but unknown
    		Null Flavor
    Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.
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