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 3 templates, Uses 5 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 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 1.3.6.1.4.1.19376.1.8.1.4.6 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
Relationship	Adaptation: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Example	generated 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/>  <text/>  <statusCode code="completed"/>  <effectiveTime>     <low value="20170224122203"/>  </effectiveTime>  <value nullFlavor="cs" value="1"/>  <interpretationCode code="A" displayName="abnormal" codeSystem="2.16.840.1.113883.5.83"/>  <referenceRange typeCode="REVF">     <observationRange classCode="OBS" moodCode="EVN.CRT">       <code code="" codeSystem="2.16.840.1.113883.5.4" displayName=""/>      <text/>      <effectiveTime value="20170224122203"/>      <value/>      <interpretation code="A" displayName="abnormal" codeSystem="2.16.840.1.113883.5.83"/>    </observationRange>  </referenceRange>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 0..* R -->   <performer>     <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (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(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></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 CWE 1 … 1 R (AssessmentScoringItemAPSR2.0)   CONF shall be drawn from concept domain "<<395527009 | Microscopic specimen observable (observable entity) |"   Example for use case #1, Breast tubule formation <code code="371470008" codeSystem="2.16.840.1.113883.6.96"/> hl7:text ED 0 … 1 R (AssessmentScoringItemAPSR2.0) hl7:statusCode CS 0 … 1 R (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 numerical score item of a scoring system, e.g. "2"  for Breast tubule formation (AssessmentScoringItemAPSR2.0) @nullFlavor cs 1 … 1 R   Example for use case #1 <value value="2"/> hl7:interpretationCode CE CWE 0 … 1 R (AssessmentScoringItemAPSR2.0)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 Observation Interpretation (HL7) (DYNAMIC) hl7:referenceRange 0 … 1 R (AssessmentScoringItemAPSR2.0) @typeCode cs 1 … 1 F REVF hl7:observationRange 0 … 1 R (AssessmentScoringItemAPSR2.0) @classCode cs 1 … 1 F OBS @moodCode cs 1 … 1 F EVN.CRT hl7:code CD CWE 1 … 1 R (AssessmentScoringItemAPSR2.0) @codeSystem CONF 1 … 1 F 2.16.840.1.113883.5.4 (Act Code) hl7:text ED 0 … 1 R (AssessmentScoringItemAPSR2.0) hl7:effectiveTime TS 0 … 1 R (AssessmentScoringItemAPSR2.0) hl7:value ANY 1 … 1 R (AssessmentScoringItemAPSR2.0) hl7:interpretation CD CWE 0 … 1 R (AssessmentScoringItemAPSR2.0)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 Observation Interpretation (HL7) (DYNAMIC) Included 0 … * R 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 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 hl7:performer 0 … * Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC) (AssessmentScoringItemAPSR2.0) hl7:author 0 … * Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author (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)