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Version vom 21. März 2017, 03:43 Uhr

Id1.3.6.1.4.1.19376.1.3.10.9.26Effective Date valid from 2014‑12‑02 16:34:50
StatusKyellow.png DraftVersion Label2.0
NameTNMNObservationDisplay NameTNM N-Observation
DescriptionTemplate CDA Observation (prototype, directly derived from POCD_RM000040 MIF)
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.26
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 4 concepts
IdNameData Set
psr-data​element-60ClinicalAPSR 2.0
psr-data​element-59PostoperativeAPSR 2.0
psr-data​element-102Sentinel Lymph NodesAPSR 2.0
psr-data​element-8N-categoryAPSR 2.0
Used by / Uses
Used by 10 templates, Uses 2 templates
Used by Template id 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.pngKvalidblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
1.3.6.1.4.1.19376.1.8.1.3.6Link.pngKyellow.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
Uses Template id as NameVersion
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen IdentifiedDYNAMIC
1.3.6.1.4.1.19376.1.3.10.9.37ContainmentKyellow.png TNM Number of nodes (2.0)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Example
Generated example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.9.26"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="21900-6 " codeSystem="2.16.840.1.113883.6.1" displayName="Regional lymph nodes.pathology [Class] Cancer"/>  <statusCode code="completed"/>  <value xsi:type="CD" code="62455006" displayName="N0 category (finding)" codeSystem="2.16.840.1.113883.6.96">
    <qualifier>
      <name code="tnmCFactor" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="C1" displayName="C1" codeSystem="2.16.840.1.113883.15.6"/>    </qualifier>    <qualifier>
      <name code="tnmCp" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="p" displayName="p" codeSystem="1.2.276.0.76.11.9"/>    </qualifier>    <qualifier>
      <name code="tnmI" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="i+" displayName="(i+)" codeSystem="2.16.840.1.113883.15.6"/>    </qualifier>    <qualifier>
      <name code="tnmMol" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="mol+" displayName="(mol+)" codeSystem="2.16.840.1.113883.15.6"/>    </qualifier>    <qualifier>
      <name code="396991001" codeSystem="2.16.840.1.113883.6.96" displayName="Biopsy site (observable entity)"/>      <value code="373193000" codeSystem="2.16.840.1.113883.6.96" displayName="Lymph node from sentinel lymph node dissection (specimen)"/>    </qualifier>  </value>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 1..* R -->
  <entryRelationship typeCode="SPRT">
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.37 'TNM Number of nodes' (dynamic) -->
  </entryRelationship></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
1 … 1R(TNMNObservation)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(TNMNObservation)
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.9.26
Treetree.pnghl7:id
II0 … *(TNMNObservation)
Treetree.pnghl7:code
CD CNE1 … 1R(TNMNObservation)
 CONF
@code shall be "21900-6 "
@codeSystem shall be "2.16.840.1.113883.6.1"
@displayName shall be "Regional lymph nodes.pathology [Class] Cancer"
@codeSystemName shall be "LOINC"
or
@code shall be "277206009"
@codeSystem shall be "2.16.840.1.113883.6.96"
@displayName shall be "N category (observable entity)"
@codeSystemName shall be "SCT"
Treetree.pnghl7:statusCode
CS1 … 1R(TNMNObservation)
 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 (DYNAMIC)
Treetree.pnghl7:value
CD1 … 1R(TNMNObservation)
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.13 UICC N category (SCT) (DYNAMIC)
or
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.16 UICC N category (DYNAMIC)
 Target.pngAssociated with concepts:
psr-data​element-8N-categoryAPSR 2.0
Treeblank.pngTreetree.pnghl7:qualifier
CR CNE0 … 1RC-Factor (Certainty)(TNMNObservation)
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV CNE1 … 1R(TNMNObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.276.0.76.3.1.131.1.5.1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1FtnmCFactor
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD CWE0 … 1R(TNMNObservation)
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.19 UICC C-Factor (DYNAMIC)
Treeblank.pngTreetree.pnghl7:qualifier
CR CWE1 … 1Rc/p/...(TNMNObservation)
 Target.pngAssociated with concepts:
psr-data​element-60ClinicalAPSR 2.0
psr-data​element-59PostoperativeAPSR 2.0
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV CNE1 … 1R(TNMNObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.276.0.76.3.1.131.1.5.1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1FtnmCp
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD CWE1 … 1R(TNMNObservation)
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.22 UICC clinical/pathological (DYNAMIC)
Treeblank.pngTreetree.pnghl7:qualifier
CR CWE0 … 1Ri (Suffix): ITC examined by Immunhistochemistry

(TNMNObservation)
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV CNE1 … 1R(TNMNObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.276.0.76.3.1.131.1.5.1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1FtnmI
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD CNE1 … 1R(TNMNObservation)
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.38 UICC Isolated Tumor Cells (DYNAMIC)
Treeblank.pngTreetree.pnghl7:qualifier
CR CWE0 … 1Rmol (Suffix): ITC examined by Molecular pathology

(TNMNObservation)
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV CNE1 … 1R(TNMNObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1FtnmMol
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.276.0.76.3.1.131.1.5.1
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD CNE1 … 1R(TNMNObservation)
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.38 UICC Isolated Tumor Cells (DYNAMIC)
Treeblank.pngTreetree.pnghl7:qualifier
CR CWE0 … 1CQualifier for Sentinel node: sn (Suffix)
(TNMNObservation)
 Target.pngAssociated with concepts:
psr-data​element-102Sentinel Lymph NodesAPSR 2.0
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV CNE1 … 1R(TNMNObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1FtnmSn
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.276.0.76.3.1.131.1.5.1
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CV CWE1 … 1R(TNMNObservation)
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.42 UICC Sentinel Node (DYNAMIC)
Included1 … *R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC)
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
 Target.pngAssociated with concepts:
psr-data​element-17Specimen identificationAPSR 2.0
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
 Target.pngAssociated with concepts:
psr-data​element-68Tissue section IDAPSR 2.0
psr-data​element-98Specimen IDAPSR 2.0
psr-data​element-66Part IDAPSR 2.0
psr-data​element-67Block IDAPSR 2.0
psr-data​element-95Parent IDAPSR 2.0
Treetree.pnghl7:entryRelationship
0 … 2RContains 1.3.6.1.4.1.19376.1.3.10.9.37 TNM Number of nodes (DYNAMIC)(TNMNObservation)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
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