1.3.6.1.4.1.19376.1.8.1.4.9/static-2014-05-14T170954: Unterschied zwischen den Versionen

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<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.9</td><th style="width: 20em; text-align: left;">Effective Date</th><td style="text-align: left;"> valid from 2014‑05‑14 17:09:54</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Draft</td><th style="width: 20em; text-align: left;">Version Label</th><td style="text-align: left;">2.0</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">APObservationEntry</td><th style="width: 20em; text-align: left;">Display Name</th><td style="text-align: left;">AP Observation Entry</td></tr><td style="text-align: left;" colspan="4"><table class="treetable" id="templateDescTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Description</td></tr><tr><td><div><span lang="EN-US" style="mso-no-proof: no">This content module is usable within a Problem organizer.<br /><br />The “AP Observation” generic template is usable for all AP observations, including ancillary techniques. </span><span lang="EN-US" style="mso-no-proof: no">
 
<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.9</td><th style="width: 20em; text-align: left;">Effective Date</th><td style="text-align: left;"> valid from 2014‑05‑14 17:09:54</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Draft</td><th style="width: 20em; text-align: left;">Version Label</th><td style="text-align: left;">2.0</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">APObservationEntry</td><th style="width: 20em; text-align: left;">Display Name</th><td style="text-align: left;">AP Observation Entry</td></tr><td style="text-align: left;" colspan="4"><table class="treetable" id="templateDescTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Description</td></tr><tr><td><div><span lang="EN-US" style="mso-no-proof: no">This content module is usable within a Problem organizer.<br /><br />The “AP Observation” generic template is usable for all AP observations, including ancillary techniques. </span><span lang="EN-US" style="mso-no-proof: no">
 
     <p class="MsoBodyText" style="MARGIN: 6pt 0cm 0pt">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.<br />
 
     <p class="MsoBodyText" style="MARGIN: 6pt 0cm 0pt">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.<br />
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     </p></span></div></td></tr></table></td><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Context</th><td style="text-align: left;" colspan="3">Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.4.9</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Label</th><td style="text-align: left;" colspan="3">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation<br /></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Classification</th><td style="text-align: left;" colspan="3">CDA Entry Level Template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Open/Closed</th><td style="text-align: left;" colspan="3">Open (other than defined elements are allowed)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Used by / Uses</th><td style="text-align: left;" colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Used by 0 transactions and 9 templates, Uses 9 templates</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Used by</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.3.6</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Problem Organizer (2.0)</td><td style="text-align: left;">2015‑08‑13 10:24:55</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.3.1</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Additional Specified Observation Section (2.0)</td><td style="text-align: left;">2016‑11‑13 14:28:08</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.1.1</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Anatomic Pathology Structured Report Content Module (2.0)</td><td style="text-align: left;">2014‑05‑13 11:57:57</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.1</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Clinical Information Section (2.0)</td><td style="text-align: left;">2014‑05‑13 14:38:08</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.2</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Intraoperative Observation Section (2.0)</td><td style="text-align: left;">2014‑05‑13 19:29:16</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.3</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Macroscopic Observation Section (2.0)</td><td style="text-align: left;">2014‑05‑13 11:57:09</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.4</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Microscopic Observation Section (2.0)</td><td style="text-align: left;">2014‑05‑13 14:25:17</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.5</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Diagnostic Conclusion Section (2.0)</td><td style="text-align: left;">2014‑05‑13 19:31:26</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.9</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] AP Observation Entry (2.0)</td><td style="text-align: left;">2014‑05‑14 17:09:54</td></tr><tr><td style="text-align: left;"></td><td style="text-align: left;" colspan="3">[[File:Notice.png|16px]] Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check</td></tr><tr><th style="width: 20%; text-align: left;">Uses</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.3.1.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Laboratory Performer (2008)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.2</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] CDA author IHE</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.6</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] CDA Informant(Header&amp;Body) APSR2 (2.0)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Additional participant in an entry APSR (Body)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.9</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] AP Observation Entry (2.0)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.10</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Embedded Image IHE</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">2.16.840.1.113883.10.12.307</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] CDA RegionOfInterest</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.5.3.1.4.2</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kcancelledblue.png|14px]] Annotation Comment (2008)</td><td style="text-align: left;">2008‑08‑08</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.9.1</td><td style="text-align: left;">Include</td><td style="text-align: left;">[[File:Kyellow.png|14px]] X Specimen Identified</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Relationship</th><td style="text-align: left;" colspan="3">Specialization: template 2.16.840.1.113883.10.12.303 (<i>2005‑09‑07</i>)</td></tr><tr class="explabel" style="vertical-align: top;"><td style="width: 20em; text-align: left;">Example</td><td colspan="3" class="explabelgreen"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Observation example</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">observation</span> <span class="ppattribute">negationInd</span><span class="ppsign">="</span><span class="ppcontent">false</span><span class="ppsign">"</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">OBS</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.8.1.4.9</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.3.999</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">--example only--</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">each_code_for_a_morphologic_abnormality_or_a_specific_procedure</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">see_above</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">normal</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20161129162112</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">ANY</span><span class="ppsign">"</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">404684003</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Clinical finding (finding)</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.96</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">interpretationCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">POS</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">abnormal</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.5.83</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">methodCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">0001</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Complement fixation</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.5.84</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">performer</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'CDA Performer IHE (Body)' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">performer</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">author</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">author</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">informant</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Body) APSR2' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">informant</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">participant</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">participant</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent"></span><span class="ppsign">"</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent"></span><span class="ppsign">"</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent"></span><span class="ppsign">"</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 0..* O --&gt;<br /></span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Card</th><th style="width: 2em; text-align: left;">Conf</th><th style="text-align: left;">Description</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:observation<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">OBS</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@moodCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@negationInd<br /></strong></tt></td></tr></table></td><td>bl</td><td><span><strong>0 … 1</strong></span></td><td> </td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.3.6.1.4.1.19376.1.8.1.4.9</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:code<br /></strong></tt></td></tr></table></td><td><strong>CE</strong> <span title="shall have coding strength &#34;CWE&#34;">CWE</span></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td><span style="text-align: justify; text-indent: -36px;">The Anatomic pathology observation code should be taken from a reference terminology, preferably the LOINC terminology. National terminologies may be used.</span></td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@code<br /></strong></tt></td></tr></table></td><td rowspan="4" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">each_code_for_observable_entities_or_a_specific_procedure</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@codeSystemName<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">LOINC</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@displayName<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">see_above</td></tr><tr class="explabel" style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelgreen"><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">59847-4</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Histology and Behavior ICD-O-3</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:text<br /></strong></tt></td></tr></table></td><td><strong>ED</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Narrative text about the observation</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:statusCode<br /></strong></tt></td></tr></table></td><td><strong>CS</strong> <span title="shall have coding strength &#34;CNE&#34;">CNE</span></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td><span style="-webkit-text-stroke-color: rgb(0, 0, 0);">The observation statusCode is “completed” if the observation was actually performed and has produced a result in the </span><span style="-webkit-text-stroke-color: rgb(0, 0, 0);">value</span><span style="-webkit-text-stroke-color: rgb(0, 0, 0);"> </span><span style="-webkit-text-stroke-color: rgb(0, 0, 0);">element. In other cases the status of the intended observation is “aborted” and the result will never come.</span></td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 <i>ActStatusAbortedCompleted </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:effectiveTime<br /></strong></tt></td></tr></table></td><td><strong>IVL_TS</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>Observation time</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:value<br /></strong></tt></td></tr></table></td><td><strong>ANY</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Observation values using the appropriate data type.<br /><br />Numeric results use data type PQ, which includes the unit. The result is absent in case of ‘aborted’ observation.<br /><br /></td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">The default data type, cardinalities and value set for the &lt;value&gt; element are dependant on the type of observation.</span></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.11 <i>AP Observation </i>(DYNAMIC)</td></tr></table></td></tr><tr class="explabel" style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelgreen"><div>for observation on tumor type</div><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">8500/3</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.43.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">ICD-O-3</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Invasive carcinoma of the breast, no special type</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:interpretationCode<br /></strong></tt></td></tr></table></td><td><strong>CE</strong> <span title="shall have coding strength &#34;CWE&#34;">CWE</span></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td><p style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51);">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:</p>
+
     </p></span></div></td></tr></table></td><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Context</th><td style="text-align: left;" colspan="3">Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.4.9</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Label</th><td style="text-align: left;" colspan="3">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation<br /></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Classification</th><td style="text-align: left;" colspan="3">CDA Entry Level Template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Open/Closed</th><td style="text-align: left;" colspan="3">Open (other than defined elements are allowed)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Used by / Uses</th><td style="text-align: left;" colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Used by 0 transactions and 9 templates, Uses 9 templates</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Used by</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.3.6</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Problem Organizer (2.0)</td><td style="text-align: left;">2015‑08‑13 10:24:55</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.3.1</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Additional Specified Observation Section (2.0)</td><td style="text-align: left;">2016‑11‑13 14:28:08</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.1.1</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Anatomic Pathology Structured Report Content Module (2.0)</td><td style="text-align: left;">2014‑05‑13 11:57:57</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.1</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Clinical Information Section (2.0)</td><td style="text-align: left;">2014‑05‑13 14:38:08</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.2</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Intraoperative Observation Section (2.0)</td><td style="text-align: left;">2014‑05‑13 19:29:16</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.3</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Macroscopic Observation Section (2.0)</td><td style="text-align: left;">2014‑05‑13 11:57:09</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.4</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Microscopic Observation Section (2.0)</td><td style="text-align: left;">2014‑05‑13 14:25:17</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.5</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Diagnostic Conclusion Section (2.0)</td><td style="text-align: left;">2014‑05‑13 19:31:26</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.9</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] AP Observation Entry (2.0)</td><td style="text-align: left;">2014‑05‑14 17:09:54</td></tr><tr><td style="text-align: left;"></td><td style="text-align: left;" colspan="3">[[File:Notice.png|16px]] Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check</td></tr><tr><th style="width: 20%; text-align: left;">Uses</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.3.1.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Laboratory Performer (2008)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.2</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] CDA author IHE</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.6</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] CDA Informant(Header&amp;Body) APSR2 (2.0)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Additional participant in an entry APSR (Body)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.9</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] AP Observation Entry (2.0)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.10</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Embedded Image IHE</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">2.16.840.1.113883.10.12.307</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] CDA RegionOfInterest</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.5.3.1.4.2</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kcancelledblue.png|14px]] Annotation Comment (2008)</td><td style="text-align: left;">2008‑08‑08</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.9.1</td><td style="text-align: left;">Include</td><td style="text-align: left;">[[File:Kyellow.png|14px]] X Specimen Identified</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Relationship</th><td style="text-align: left;" colspan="3">Specialization: template 2.16.840.1.113883.10.12.303 (<i>2005‑09‑07</i>)</td></tr><tr class="explabel" style="vertical-align: top;"><td style="width: 20em; text-align: left;">Example</td><td colspan="3" class="explabelgreen"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Observation example</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">observation</span> <span class="ppattribute">negationInd</span><span class="ppsign">="</span><span class="ppcontent">false</span><span class="ppsign">"</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">OBS</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.8.1.4.9</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.3.999</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">--example only--</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">each_code_for_a_morphologic_abnormality_or_a_specific_procedure</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">see_above</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">normal</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20161129162112</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">ANY</span><span class="ppsign">"</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">404684003</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Clinical finding (finding)</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.96</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">interpretationCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">POS</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">abnormal</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.5.83</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">methodCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">0001</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Complement fixation</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.5.84</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">performer</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'CDA Performer IHE (Body)' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">performer</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">author</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">author</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">informant</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Body) APSR2' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">informant</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">participant</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">participant</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent"></span><span class="ppsign">"</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent"></span><span class="ppsign">"</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent"></span><span class="ppsign">"</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 0..* O --&gt;<br /></span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Card</th><th style="width: 2em; text-align: left;">Conf</th><th style="text-align: left;">Description</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:observation<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">OBS</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@moodCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@negationInd<br /></strong></tt></td></tr></table></td><td>bl</td><td><span><strong>0 … 1</strong></span></td><td> </td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.3.6.1.4.1.19376.1.8.1.4.9</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:code<br /></strong></tt></td></tr></table></td><td><strong>CE</strong> <span title="shall have coding strength &#34;CWE&#34;">CWE</span></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td><span style="text-align: justify; text-indent: -36px;">The Anatomic pathology observation code should be taken from a reference terminology, preferably the LOINC terminology. National terminologies may be used.</span></td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@code<br /></strong></tt></td></tr></table></td><td rowspan="4" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">each_code_for_observable_entities_or_a_specific_procedure</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@codeSystemName<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">LOINC</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@displayName<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">see_above</td></tr><tr class="explabel" style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelgreen"><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">59847-4</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Histology and Behavior ICD-O-3</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:text<br /></strong></tt></td></tr></table></td><td><strong>ED</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Narrative text about the observation</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:statusCode<br /></strong></tt></td></tr></table></td><td><strong>CS</strong> <span title="shall have coding strength &#34;CNE&#34;">CNE</span></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td><span style="-webkit-text-stroke-color: rgb(0, 0, 0);">The observation statusCode is “completed” if the observation was actually performed and has produced a result in the </span><span style="-webkit-text-stroke-color: rgb(0, 0, 0);">value</span><span style="-webkit-text-stroke-color: rgb(0, 0, 0);"> </span><span style="-webkit-text-stroke-color: rgb(0, 0, 0);">element. In other cases the status of the intended observation is “aborted” and the result will never come.</span></td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 <i>ActStatusAbortedCompleted </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:effectiveTime<br /></strong></tt></td></tr></table></td><td><strong>IVL_TS</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>Observation time</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:value<br /></strong></tt></td></tr></table></td><td><strong>ANY</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Observation values using the appropriate data type.<br /><br />Numeric results use data type PQ, which includes the unit. The result is absent in case of ‘aborted’ observation.<br /><br /></td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">The default data type, cardinalities and value set for the &lt;value&gt; element are dependant on the type of observation.</span></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.11 <i>AP Observation </i>(DYNAMIC)</td></tr></table></td></tr><tr class="explabel" style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelgreen"><div>for observation on tumor type</div><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">8500/3</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.43.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">ICD-O-3</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Invasive carcinoma of the breast, no special type</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:interpretationCode<br /></strong></tt></td></tr></table></td><td><strong>CE</strong> <span title="shall have coding strength &#34;CWE&#34;">CWE</span></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td><p style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51);">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:</p>
 
<ul style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51);">
 
<ul style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51);">
 
     <li>S = susceptible</li>
 
     <li>S = susceptible</li>
Zeile 10: Zeile 10:
 
<p style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51);">This element may be coded with other values than those of the ObservationInterpretation vocabulary, given that the coding strength is CWE (coded with exceptions).</p></td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 <i>Observation Interpretation (HL7) </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:methodCode<br /></strong></tt></td></tr></table></td><td><strong>CE</strong> <span title="shall have coding strength &#34;CWE&#34;">CWE</span></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14079 <i>ObservationMethod </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:performer<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>C</strong></span></td><td>Performing lab<br /><br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF-3: 6.3.2.20</span><br /><br />Contains 1.3.6.1.4.1.19376.1.3.3.1.7 <i>Laboratory Performer</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">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.</span><br /></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:author<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>C</strong></span></td><td>Author<br /><br />
 
<p style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51);">This element may be coded with other values than those of the ObservationInterpretation vocabulary, given that the coding strength is CWE (coded with exceptions).</p></td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 <i>Observation Interpretation (HL7) </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:methodCode<br /></strong></tt></td></tr></table></td><td><strong>CE</strong> <span title="shall have coding strength &#34;CWE&#34;">CWE</span></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14079 <i>ObservationMethod </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:performer<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>C</strong></span></td><td>Performing lab<br /><br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF-3: 6.3.2.20</span><br /><br />Contains 1.3.6.1.4.1.19376.1.3.3.1.7 <i>Laboratory Performer</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">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.</span><br /></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:author<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>C</strong></span></td><td>Author<br /><br />
 
<div><span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">Source: PaLM TF Suppl. APSR 2.0-3:</span><span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);"> 6.3.6.2</span>
 
<div><span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">Source: PaLM TF Suppl. APSR 2.0-3:</span><span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);"> 6.3.6.2</span>
−
</div><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.2 <i>CDA author IHE</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:informant<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Informant<br /><br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF Suppl. APSR 2.0-3</span><span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">: 6.3.6.5</span><br /><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.6 <i>CDA Informant(Header&amp;Body) APSR2</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:participant<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Additional participants<br /><br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF Suppl. APSR 2.0-3</span><span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">: 6.3.6.6</span><br /><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.7 <i>Additional participant in an entry APSR (Body)</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entryRelationship<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Sub-Observation<br /><br /><span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">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.</span><br />
+
</div><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.2 <i>CDA author IHE</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:informant<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Informant<br /><br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF Suppl. APSR 2.0-3</span><span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">: 6.3.6.5</span><br /><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.6 <i>CDA Informant(Header&amp;Body) APSR2</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:participant<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Additional participants<br /><br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF Suppl. APSR 2.0-3</span><span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">: 6.3.6.6</span><br /><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.7 <i>Additional participant in an entry APSR (Body)</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entryRelationship<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Sub-Observation<br /><br /><span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">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.</span><br />
 
<div><span style="font-kerning: none"><br />Source: </span>Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF Suppl. APSR 2.0-3</span><span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">: 6.3.6.7</span>
 
<div><span style="font-kerning: none"><br />Source: </span>Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF Suppl. APSR 2.0-3</span><span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">: 6.3.6.7</span>
−
</div><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.9 <i>AP Observation Entry</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entryRelationship<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Embedded image. <br /><br /><span style="-webkit-text-stroke-color: rgb(0, 0, 0);">This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest. </span><br /><br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF Suppl. APSR 2.0-3</span><span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">: 6.3.6.8</span><br /><br />
+
</div><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.9 <i>AP Observation Entry</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entryRelationship<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Embedded image. <br /><br /><span style="-webkit-text-stroke-color: rgb(0, 0, 0);">This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest. </span><br /><br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF Suppl. APSR 2.0-3</span><span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">: 6.3.6.8</span><br /><br />
 
<div><span style="font-kerning: none"><br /></span>
 
<div><span style="font-kerning: none"><br /></span>
−
</div><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.10 <i>Embedded Image IHE</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entryRelationship<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Region of Interest<br /><br /><br /><br /><br /><br />
+
</div><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.10 <i>Embedded Image IHE</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entryRelationship<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Region of Interest<br /><br /><br /><br /><br /><br />
 
<div><span style="font-kerning: none"><br /></span>
 
<div><span style="font-kerning: none"><br /></span>
−
</div><br />Contains 2.16.840.1.113883.10.12.307 <i>CDA RegionOfInterest</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><span style="-webkit-text-stroke-color: rgb(0, 0, 0);">This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest. <br />In the latter case by an entryRelationship @typeCode="SUBJ"</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entryRelationship<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Annotation comment<br /><br /><br /><br /><br /><br />
+
</div><br />Contains 2.16.840.1.113883.10.12.307 <i>CDA RegionOfInterest</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><span style="-webkit-text-stroke-color: rgb(0, 0, 0);">This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest. <br />In the latter case by an entryRelationship @typeCode="SUBJ"</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entryRelationship<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Annotation comment<br /><br /><br /><br /><br /><br />
 
<div><span style="font-kerning: none"><br /></span>
 
<div><span style="font-kerning: none"><br /></span>
 
</div><br />Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 <i>Annotation Comment</i> (2008‑08‑08)</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Included</td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td colspan="2"> from 1.3.6.1.4.1.19376.1.3.10.9.1 <i>X Specimen Identified</i> (DYNAMIC)<br />Specimen identification<br /></td></tr><tr class="explabel" style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelgreen"><div>Example for specimen referencing</div><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">specimen</span><span class="ppsign">&gt;</span><br /><span style="display: block;">  <span style="color:green">&lt;!-- which specimen is used for this observation --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">specimenRole</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.8.1.4.999999</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">slide_A_1_PR</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">specimenRole</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">specimen</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:specimen<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>Required in XD-LAB when more than one specimen is documented at this level. Always required in APSR.<br /></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SPC</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:specimenRole<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SPEC</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Specimen ID, coming from the LIS</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified</span></td></tr></table></td></tr></table>
 
</div><br />Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 <i>Annotation Comment</i> (2008‑08‑08)</td><td style="background-color: #FFEEEE;"><span title="">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Included</td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td colspan="2"> from 1.3.6.1.4.1.19376.1.3.10.9.1 <i>X Specimen Identified</i> (DYNAMIC)<br />Specimen identification<br /></td></tr><tr class="explabel" style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelgreen"><div>Example for specimen referencing</div><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">specimen</span><span class="ppsign">&gt;</span><br /><span style="display: block;">  <span style="color:green">&lt;!-- which specimen is used for this observation --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">specimenRole</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.8.1.4.999999</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">slide_A_1_PR</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">specimenRole</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">specimen</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:specimen<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>Required in XD-LAB when more than one specimen is documented at this level. Always required in APSR.<br /></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SPC</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:specimenRole<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SPEC</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Specimen ID, coming from the LIS</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified</span></td></tr></table></td></tr></table>

Version vom 4. Juli 2017, 02:20 Uhr

Id1.3.6.1.4.1.19376.1.8.1.4.9Effective Date valid from 2014‑05‑14 17:09:54
StatusKyellow.png DraftVersion Label2.0
NameAPObservationEntryDisplay NameAP 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.

ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.4.9
LabelPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 9 templates, Uses 9 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.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
1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2008)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA author IHEDYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.7ContainmentKyellow.png Additional participant in an entry APSR (Body)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.10ContainmentKyellow.png Embedded Image IHEDYNAMIC
2.16.840.1.113883.10.12.307ContainmentKgreen.png CDA RegionOfInterestDYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.2ContainmentKcancelledblue.png Annotation Comment (2008)2008‑08‑08
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen IdentifiedDYNAMIC
RelationshipSpecialization: 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="POS" 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>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … *RPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1MPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.9
Treetree.pnghl7:id
II0 … *RPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treetree.pnghl7:code
CE CWE1 … 1MThe 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
Treeblank.pngTreetree.png@code
CONF1 … 1Feach_code_for_observable_entities_or_a_specific_procedure
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1Fsee_above
 Example<code code="59847-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Histology and Behavior ICD-O-3"/>
Treetree.pnghl7:text
ED0 … 1RNarrative text about the observationPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treetree.pnghl7:statusCode
CS CNE1 … 1MThe 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.PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 ActStatusAbortedCompleted (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1MObservation timePaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treetree.pnghl7:value
ANY0 … *RObservation 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
 ConstraintThe 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"/>
Treetree.pnghl7:interpretationCode
CE CWE0 … 1R

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)
Treetree.pnghl7:methodCode
CE CWE0 … 1RPaLM 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)
Treetree.pnghl7:performer
II0 … 1CPerforming 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
 ConstraintThe 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.
Treetree.pnghl7:author
II0 … *CAuthor

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 IHE (DYNAMIC)		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treetree.pnghl7:informant
II0 … *RInformant

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
Treetree.pnghl7:participant
II0 … *RAdditional 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
Treetree.pnghl7:entryRelationship
0 … *RSub-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
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7:entryRelationship
0 … *REmbedded 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
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7:entryRelationship
0 … *RRegion 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
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
 ConstraintThis 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"
Treetree.pnghl7:entryRelationship
0 … *RAnnotation comment

Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 Annotation Comment (2008‑08‑08)		PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCOMP
Included1 … *M 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>
Treetree.pnghl7:specimen
1 … *MRequired 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
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
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