1.3.6.1.4.1.19376.1.8.1.4.9/static-2014-05-14T170954

Id	1.3.6.1.4.1.19376.1.8.1.4.9	Effective Date	valid from 2014‑05‑14 17:09:54
Status	Draft	Version Label	2.0
Name	APObservationEntry	Display Name	AP 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.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.4.9
Label	PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Classification	CDA Entry Level Template
Open/Closed	Closed (only defined elements are allowed)
Associated with	Associated with 3 concepts Id Name Data Set psr-data​element-47 Observation APSR 2.0 psr-data​element-65 Generic AP observation APSR 2.0 psr-data​element-57 Scoring systems APSR 2.0
Used by / Uses	Used by 9 templates, Uses 8 templates Used by Template id as Name Version 1.3.6.1.4.1.19376.1.8.1.3.6 Containment 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 Content Module (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 1.3.6.1.4.1.19376.1.8.1.4.9 Containment AP Observation Entry (2.0) 2014‑05‑14 17:09:54 Uses Template id as Name Version 1.3.6.1.4.1.19376.1.3.3.1.7 Containment Laboratory Performer (2008) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.4.2 Containment CDA author 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 1.3.6.1.4.1.19376.1.8.1.4.10 Containment Embedded Image IHE DYNAMIC 2.16.840.1.113883.10.12.307 Containment CDA RegionOfInterest DYNAMIC 1.3.6.1.4.1.19376.1.3.10.9.1 Include X Specimen Identified DYNAMIC
Relationship	Specialization: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Example	Observation example <observation negationInd="false" classCode="OBS" moodCode="EVN">   <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="each_code_for_a_morphologic_abnormality_or_a_specific_procedure" codeSystem="2.16.840.1.113883.6.1" displayName="see_above"/>  <text/>  <statusCode code="normal"/>  <effectiveTime>     <low value="20161129162112"/>  </effectiveTime>  <value xsi:type="ANY" code="404684003" displayName="Clinical finding (finding)" codeSystem="2.16.840.1.113883.6.96"/>  <interpretationCode code="A" displayName="abnormal" codeSystem="2.16.840.1.113883.5.83"/>  <methodCode code="0001" displayName="Complement fixation" 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 --> </observation>
Item DT Card Conf Description Label hl7:observation 0 … * R PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation @classCode cs 1 … 1 F OBS @moodCode cs 1 … 1 F EVN @negationInd bl 0 … 1     Associated with concepts: psr-data​element-47 Observation APSR 2.0 psr-data​element-65 Generic AP observation APSR 2.0 psr-data​element-57 Scoring systems APSR 2.0 hl7:templateId II 1 … 1 M PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.4.9 hl7:id II 0 … * PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation hl7:code CE CWE 1 … 1 M The 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 @code CONF 1 … 1 F each_code_for_observable_entities_or_a_specific_procedure @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) @displayName 1 … 1 F see_above @codeSystemName 1 … 1 F LOINC   Example <code code="59847-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Histology and Behavior ICD-O-3"/> hl7:text ED 0 … 1 Narrative text about the observation PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation hl7:statusCode CS CNE 1 … 1 M PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation   Constraint The 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 (DYNAMIC) hl7:effectiveTime IVL_TS 1 … 1 M Observation time PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation hl7:value ANY 0 … * R Observation 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   Constraint The default data type, cardinalities and value set for the <value> element are dependant on the type of observation.   Constraint   CONF The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.11 AP Observation (DYNAMIC)   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"/> hl7:interpretationCode CE CWE 0 … 1 R One or more codes interpreting the result, expressed with ObservationInterpretation vocabulary (e.g., H = high, L = low). In case of a antimicrobial susceptibility test in microbiology, the vocabulary domain is ObservationInterpretationSusceptibility: S = susceptible R = resistant I = intermediate SDD = Susceptible-dose dependent 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 shall be drawn from value set 2.16.840.1.113883.1.11.78 Observation Interpretation (HL7) (DYNAMIC) hl7:methodCode CE CWE 0 … 1 R PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (DYNAMIC) hl7:performer II 0 … 1 C Performing lab Source: PaLM TF-3: 6.3.2.20 Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC) PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation   Constraint The 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. hl7:author II 0 … * C Author 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 (DYNAMIC) PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation hl7:informant II 0 … * Informant 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 (DYNAMIC) PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation hl7:participant II 0 … * Additional 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) (DYNAMIC) PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation hl7:entryRelationship 0 … * Sub-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 (DYNAMIC) PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation @typeCode cs 1 … 1 F COMP hl7:entryRelationship 0 … * Embedded 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 (DYNAMIC) PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation @typeCode cs 1 … 1 F COMP hl7:entryRelationship 0 … * Region of Interest Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (DYNAMIC) PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation @typeCode cs 1 … 1 F COMP   Constraint This 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" Included 1 … * R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC) 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> hl7:specimen 1 … * 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