1.3.6.1.4.1.19376.1.3.10.4.1/static-2016-07-08T132059

Id	1.3.6.1.4.1.19376.1.3.10.4.1	Effective 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
Status	Draft	Version Label	2.0
Name	SpecimenProcedureStep	Display Name	Specimen 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.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.1
Label	PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Classification	CDA Entry Level Template
Open/Closed	Closed (only defined elements are allowed)
Associated with	Associated with 6 concepts Id Name Data Set psr-data​element-24 Specimen collection APSR 2.0 psr-data​element-25 Specimen processing APSR 2.0 psr-data​element-87 Procedure ID APSR 2.0 psr-data​element-89 Procedure Step APSR 2.0 psr-data​element-90 Requested Procedure APSR 2.0 psr-data​element-94 Target Site APSR 2.0
Used by / Uses	Used by 4 templates, Uses 7 templates Used by Template id as Name Version 1.3.6.1.4.1.19376.1.3.10.4.1 Containment Specimen Procedure Step (2.0) 2016‑07‑08 13:20:59 1.3.6.1.4.1.19376.1.3.10.4.1 Specimen Procedure Step (1.0) 2014‑07‑29 16:02:02 1.3.6.1.4.1.19376.1.8.1.2.6 Procedure Steps Section (2.0) 2014‑05‑13 19:33:12 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 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 Laboratory Performer (2008) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.4.2 Containment CDA author DYNAMIC 1.3.6.1.4.1.19376.1.3.10.9.20 Containment CDA Participant (Body) Procedure Steps APSR2 (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.3.10.9.22 Containment CDA Supply Container APSR2 (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.3.1.3 Containment Specimen Received (2008) DYNAMIC
Relationship	Specialization: template 2.16.840.1.113883.10.12.306 (2005‑09‑07) Specialization: template 1.3.6.1.4.1.19376.1.3.1.2 (2016‑07‑05)
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 nullFlavor="cs" code="23307004" codeSystem="2.16.840.1.113883.6.96" displayName="Estrogen receptor (substance)"/>    </qualifier>  </code>  <text/>  <statusCode code="normal"/>  <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 'CDA Performer IHE (Body)' (dynamic) -->   </performer>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) -->   </author>  <participant>     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.20 'CDA Participant (Body) Procedure Steps APSR2' (dynamic) -->   </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' (dynamic) -->   </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' (dynamic) -->   </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' (dynamic) -->   </entryRelationship></procedure>
Item DT Card Conf Description Label hl7:procedure 1 … * R PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps @classCode cs 1 … 1 F PROC @moodCode cs 1 … 1 F EVN @negationInd bl 0 … 1     Associated with concepts: psr-data​element-24 Specimen collection APSR 2.0 psr-data​element-25 Specimen processing APSR 2.0 psr-data​element-90 Requested Procedure APSR 2.0 hl7:templateId II 1 … 1 R PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.10.4.1 hl7:id II 1 … 1 M Procedure 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   Associated with concepts: psr-data​element-87 Procedure ID APSR 2.0 psr-data​element-89 Procedure Step APSR 2.0 hl7:code CD CWE 1 … 1 M Coded procedure PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps   Constraint   CONF The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.10 Specimen Collection and Processing (DYNAMIC)   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)"/> hl7:qualifier CR 0 … * C Qualifier 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   Constraint Used 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> hl7:name CV 1 … 1 R PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps @code cs 1 … 1 F 246094008 or 246355002 @codeSystem cs 1 … 1 F 2.16.840.1.113883.6.96 @displayName cs 0 … 1 F Component investigated (attribute) or Supporting structure (attribute) hl7:value CD CWE 1 … 1 R PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps @nullFlavor cs 1 … 1 R   CONF @code shall be "<<105590001 | Substance (substance) |" @codeSystem shall be "2.16.840.1.113883.6.96" @displayName shall be "values from substance axis, e.g. Estrogen receptor" @codeSystemName shall be "SNOMED-CT" or @code shall be "values from G axis" @codeSystem shall be "2.16.840.1.113883.6.174" @displayName shall be "values from G axis, e.g. erb-b2" @codeSystemName shall be "OMIM" or @code shall be "<<272394005 | Technique (qualifier value) |" @codeSystem shall be "2.16.840.1.113883.6.96" @displayName shall be "values from technique axis, e.g. Paraffin embedded (qualifier)" @codeSystemName shall be "SNOMED-CT" hl7:text ED 0 … 1 R PaLM 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> hl7:statusCode CS CNE 1 … 1 R PaLM 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) hl7:effectiveTime IVL_TS 0 … 1 R PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps hl7:target​Site​Code CD CWE 0 … * R target site in body or relative parent relationship in case of  specimen processing PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps   CONF @codeSystem shall be "2.16.840.1.113883.5.1052" or The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.9 Procedure Site (DYNAMIC) or @code shall be "<<123037004 | Body structure (body structure) |" @codeSystem shall be "2.16.840.1.113883.6.96" @displayName shall be "all children of Body structure (body structure)" @codeSystemName shall be "SCT"   Associated with concepts: psr-data​element-94 Target Site APSR 2.0   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"/> hl7:qualifier CR 0 … * optional qualifiers for specifying body structures or / and laterality PaLM 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> hl7:name CV 1 … 1 R PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps @displayName st 0 … 1 F Specimen source topography @codeSystem oid 1 … 1 F 2.16.840.1.113883.6.96 @code cs 1 … 1 F 118169006 hl7:value CD CWE 0 … * R PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps @code CONF 1 … 1   @code shall be out of choice: <<272099008 Descriptor (qualifier value) @codeSystem 1 … 1 F 2.16.840.1.113883.6.96 (SNOMED Clinical Terms) @displayName 1 … 1 F all children of "Descriptor, qualifier values", e.g. right lower quadrantt @codeSystemName 1 … 1 F SCT hl7:methodCode CD 0 … * Identifies the technique used to perform a procedure PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps @codeSystem cs 1 … 1 F 2.16.840.1.113883.5.1065 Included 0 … * R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC) 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" extension="A7102400008"/>  </specimenRole></specimen> 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 Laboratory Performer (DYNAMIC) PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps hl7:author 0 … * Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author (DYNAMIC) PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps hl7:participant 1 … * M One or more specimen (with additives), which participates as product of the procedure Contains 1.3.6.1.4.1.19376.1.3.10.9.20 CDA Participant (Body) Procedure Steps APSR2 (DYNAMIC) PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps where [not(@nullFlavor)] hl7:entryRelationship 0 … * R Artificial material (manufactured product) which containes the specimen Contains 1.3.6.1.4.1.19376.1.3.10.9.22 CDA Supply Container APSR2 (DYNAMIC) PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true @inversionInd bl 0 … 1   @negationInd bl 0 … 1     Constraint for manufactured product classCode = MANU for DrugOrOtherMaterial classCode = MMAT code from MaterialEntityClassType hl7:seperatableInd BL 0 … * PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps hl7:entryRelationship 0 … 1 R Specimen arrival in Lab Contains 1.3.6.1.4.1.19376.1.3.1.3 Specimen Received (DYNAMIC) PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true @inversionInd bl 0 … 1   @negationInd bl 0 … 1     Constraint hl7:seperatableInd BL 0 … * PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps hl7:sequenceNumber INT 0 … * PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps hl7:entryRelationship 0 … * R Referencing mechanism to the ID of the child procedures Contains 1.3.6.1.4.1.19376.1.3.10.4.1 Specimen Procedure Step (DYNAMIC) PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps @typeCode cs 1 … 1 F REFR @context​Conduction​Ind bl 0 … 1 F true @inversionInd bl 0 … 1   @negationInd bl 0 … 1     Constraint contains only ID of the child procedure, which is fully described in a dedicated entry further down in the Procedure step section. hl7:seperatableInd BL 0 … * PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps