1.3.6.1.4.1.19376.1.3.10.4.3/static-2015-11-29T170318

Id	1.3.6.1.4.1.19376.1.3.10.4.3	Effective Date	valid from 2015‑11‑29 17:03:18
Status	Draft	Version Label	2.0
Name	ICD-O-3TypingGrading	Display Name	ICD-O-3 Typing and Grading Observation
Description	Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF) Entry template for observation on ICD-O-3 Typing and Grading
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.3
Label	PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 0 templates, Uses 7 templates Uses as Name Version 1.3.6.1.4.1.19376.1.8.1.4.2 Containment CDA author IHE DYNAMIC 1.3.6.1.4.1.19376.1.3.10.9.1 Include X Specimen Identified DYNAMIC 1.3.6.1.4.1.19376.1.3.10.9.38 Containment ICD-O-3 Behavior (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.3.10.9.39 Containment ICD-O-3 Differentiation (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.3.10.4.4 Containment Assessment Scales Observation for Scoring Systems 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	Specialization: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Example	example for use case #1 <observation classCode="OBS" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.3.10.4.3"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_ICDO"/>  <code code="59847-4" codeSystem="2.16.840.1.113883.6.1" displayName="Histology and behavior ICD-O-3"/>  <originalText/>  <statusCode code="completed"/>  <effectiveTime>     <low value="201001041405-0500"/>  </effectiveTime>  <value xsi:type="CD" code="8500/3" codeSystem="2.16.840.1.113883.6.43.1"/>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) -->   </author>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 1..* R -->   <specimen typeCode="SPC">     <specimenRole classCode="SPEC">       <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7591/16"/>    </specimenRole>  </specimen>  <entryRelationship typeCode="SPRT">     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.38 'ICD-O-3 Behavior' (dynamic), not used in use case #1 -->   </entryRelationship>  <entryRelationship typeCode="SPRT">     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.39 'ICD-O-3 Differentiation' (dynamic) -->   </entryRelationship>  <entryRelationship typeCode="COMP">     <!-- template 1.3.6.1.4.1.19376.1.3.10.4.4 'Assessment Scales Observation for Scoring Systems APSR2' (dynamic) -->   </entryRelationship>  <reference>     <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (dynamic) -->   </reference></observation>
Item DT Card Conf Description Label hl7:observation 0 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 @classCode cs 0 … 1 F OBS @moodCode cs 1 … 1 F EVN hl7:templateId II 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.10.4.3 hl7:id II 0 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 hl7:code CD CWE 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3   CONF @code shall be "59847-4" @codeSystem shall be "2.16.840.1.113883.6.1" @codeSystemName shall be "LOINC" @displayName shall be "Histology and behavior ICD-O-3" or @code shall be "397005006" @codeSystem shall be "2.16.840.1.113883.6.96" @codeSystemName shall be "SNOMED-CT" @displayName shall be "WHO tumor classification (observable entity)" hl7:originalText ED 0 … 1 R Original text of the Morphology code with supporting Differentiation code: e.g. 8500/31 PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3   Example for use case #1 <text>8500/31</text> hl7:statusCode CS CNE 1 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3   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 R PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 hl7:value CD 1 … 1 R Morphology axis code. A complete code consists of 6 digits (for morphology, behavior and grading), the latter both separated by "/" after the 4th digit in morphology. Behavior and differentiation are coded as sub-observations PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3   CONF The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.33 ICD-O-3 Morphology and Behavior (DYNAMIC)   Example for use case #1: invasive breast cancer, NST, well differentiated <value xsi:type="CD" code="8500/3" codeSystem="2.16.840.1.113883.6.43.1"/> hl7:author 0 … 1 C Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 Included 1 … * R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC) 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 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:entryRelationship 0 … 1 C 5th digit in the morphology code, used only if this digit is deviant from the code list in morphology axis Contains 1.3.6.1.4.1.19376.1.3.10.9.38 ICD-O-3 Behavior (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 @typeCode cs 1 … 1 F SPRT hl7:entryRelationship 0 … 1 R 6th digit in the morphology code Contains 1.3.6.1.4.1.19376.1.3.10.9.39 ICD-O-3 Differentiation (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 @typeCode cs 1 … 1 F SPRT hl7:entryRelationship 0 … 1 R optional grading by a scoring system, e.g. by means of the Elston-Ellis-Scoring-System in case of invasive breast cancer (ICD-O C50) Contains 1.3.6.1.4.1.19376.1.3.10.4.4 Assessment Scales Observation for Scoring Systems APSR2 (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 @typeCode cs 1 … 1 F COMP hl7:participant 0 … * Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry APSR (Body) (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 hl7:reference 0 … * Contains 2.16.840.1.113883.10.12.324 CDA Reference (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3