1.3.6.1.4.1.19376.1.3.10.9.43/static-2016-10-11T102617

Id	1.3.6.1.4.1.19376.1.3.10.9.43	Effective Date	valid from 2016‑10‑11 10:26:17
Status	Draft	Version Label	2.0
Name	AssessmentScoringItemAPSR2.0	Display Name	Assessment Scoring Item APSR 2.0
Description	Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF) Supportive Observation entry template for describing the granular Items for a scoring system, e.g.Elston-Ellis-Score or Gleason Score
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.43
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 11 templates, Uses 6 templates Used by Template id as Name Version 1.3.6.1.4.1.19376.1.3.10.9.42 Containment Assessment Scoring System APSR 2.0 (2.0) 2016‑10‑10 11:33:36 1.3.6.1.4.1.19376.1.3.10.4.4 Assessment Scales Observation for Scoring Systems APSR2 (2.0) 2016‑10‑06 13:12:00 1.3.6.1.4.1.19376.1.3.10.4.3 ICD-O-3 Typing and Grading Observation (2.0) 2015‑11‑29 17:03:18 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (2.0) 2015‑08‑13 10:24:55 1.3.6.1.4.1.19376.1.3.10.3.1 Additional Specified Observation Section (2.0) 2016‑11‑13 14:28:08 1.3.6.1.4.1.19376.1.8.1.1.1 Anatomic Pathology Structured Report (2.0) 2014‑05‑13 11:57:57 1.3.6.1.4.1.19376.1.8.1.2.1 Clinical Information Section (2.0) 2014‑05‑13 14:38:08 1.3.6.1.4.1.19376.1.8.1.2.2 Intraoperative Observation Section (2.0) 2014‑05‑13 19:29:16 1.3.6.1.4.1.19376.1.8.1.2.3 Macroscopic Observation Section (2.0) 2014‑05‑13 11:57:09 1.3.6.1.4.1.19376.1.8.1.2.4 Microscopic Observation Section (2.0) 2014‑05‑13 14:25:17 1.3.6.1.4.1.19376.1.8.1.2.5 Diagnostic Conclusion Section (2.0) 2014‑05‑13 19:31:26 Uses Template id as Name Version 1.3.6.1.4.1.19376.1.3.10.9.1 Include X Specimen Identified DYNAMIC 1.3.6.1.4.1.19376.1.3.3.1.7 Containment CDA Performer IHE (Body) DYNAMIC 2.16.840.1.113883.10.12.318 Containment CDA Author (Body) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.4.6 Containment CDA Informant(Header&Body) APSR2 (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.4.7 Containment Additional participant in an entry APSR (Body) DYNAMIC 2.16.840.1.113883.10.12.324 Containment CDA Reference DYNAMIC
Relationship	Adaptation: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Example	Example <observation negationInd="false" classCode="OBS" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.3.10.9.43"/>  <id root="1.2.3.999" extension="--example only--"/>  <code/>  <derivationExpr/>  <text/>  <statusCode code="normal"/>  <effectiveTime>     <low value="20170131163501"/>  </effectiveTime>  <value nullFlavor="cs" value="1"/>  <methodCode code="0001" displayName="Complement fixation" codeSystem="2.16.840.1.113883.5.84"/>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 0..* O -->   <performer>     <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'CDA Performer IHE (Body)' (dynamic) -->   </performer>  <author>     <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' (dynamic) -->   </author>  <informant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&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>  <reference>     <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (dynamic) -->   </reference></observation>
Item DT Card Conf Description Label hl7:observation (AssessmentScoringItemAPSR2.0) @classCode cs 0 … 1 F OBS @moodCode cs 1 … 1 F EVN @negationInd bl 0 … 1   hl7:templateId II 1 … 1 M (AssessmentScoringItemAPSR2.0) @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.10.9.43 hl7:id II 1 … 1 R (AssessmentScoringItemAPSR2.0) hl7:code CE 1 … 1 R (AssessmentScoringItemAPSR2.0)   CONF shall be drawn from concept domain "any code for scoring items (children of Microscopic specimen observable (observable entity)), e.g. 2.16.840.1.113883.1.11.16226 Breast tubule formation"   Example Breast tubule formation <code code="371470008" codeSystem="2.16.840.1.113883.6.96"/> hl7:derivationExpr ST 0 … 1 (AssessmentScoringItemAPSR2.0) hl7:text ED 0 … 1 R (AssessmentScoringItemAPSR2.0) hl7:statusCode CS 0 … 1 (AssessmentScoringItemAPSR2.0)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC) hl7:effectiveTime IVL_TS 0 … 1 (AssessmentScoringItemAPSR2.0) hl7:value INT 1 … 1 R Single coded numerical score item of a scoring system, e.g. 3 for Breast tubule formation (SCT) (AssessmentScoringItemAPSR2.0) @nullFlavor cs 1 … 1 R hl7:methodCode CE 0 … * (AssessmentScoringItemAPSR2.0)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (DYNAMIC) or @code shall be "MSRSCORE" @codeSystem shall be "2.16.840.1.113883.1.11.16226" @displayName shall be "measure scoring" @codeSystemName shall be "HL7 Observation type" Included 0 … * from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC) hl7:specimen 0 … * R Required in XD-LAB when more than one specimen is documented at this level. Always required in APSR. PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified @typeCode cs 0 … 1 F SPC   Associated with concepts: psr-data​element-17 Specimen identification APSR 2.0 hl7:specimenRole 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified @classCode cs 0 … 1 F SPEC hl7:id II 1 … 1 R Specimen ID, coming from the LIS PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified   Associated with concepts: psr-data​element-68 Tissue section ID APSR 2.0 psr-data​element-98 Specimen ID APSR 2.0 psr-data​element-66 Part ID APSR 2.0 psr-data​element-67 Block ID APSR 2.0 psr-data​element-95 Parent ID APSR 2.0 hl7:performer 0 … * Contains 1.3.6.1.4.1.19376.1.3.3.1.7 CDA Performer IHE (Body) (DYNAMIC) (AssessmentScoringItemAPSR2.0) hl7:author 0 … * Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC) (AssessmentScoringItemAPSR2.0) hl7:informant 0 … * Contains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (DYNAMIC) (AssessmentScoringItemAPSR2.0) hl7:participant 0 … * Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry APSR (Body) (DYNAMIC) (AssessmentScoringItemAPSR2.0) hl7:reference 0 … * Contains 2.16.840.1.113883.10.12.324 CDA Reference (DYNAMIC) (AssessmentScoringItemAPSR2.0)