1.3.6.1.4.1.19376.1.8.1.1.1/static-2014-05-13T115757

Id	1.3.6.1.4.1.19376.1.8.1.1.1	Effective Date	valid from 2014‑05‑13 11:57:57
Status	Draft	Version Label	2.0
Name	AnatomicPathologyStructuredReportContentModule	Display Name	Anatomic Pathology Structured Report Content Module
Description Anatomic Pathology Structured Report Content Module.  This document content module represents the generic set of constraints applied to any structured report for surgical pathology in all fields of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as for Cytopathology.  The body of this Document Content Module specifies a common hierarchy of sections and entries depicted by figure 10.4.1-1 in Volume 1 IHE_PaLM_Suppl_APSR 2.0. The only mandatory section is the Diagnostic Conclusion Section. And the only mandatory entry is the Problem Organizer Entry below this section.
Context	Pathname /
Label	PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Classification	CDA Document Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 0 templates, Uses 19 templates Uses as Name Version 1.3.6.1.4.1.19376.1.3.3.1.1 Include Human Patient (2017) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.4.2 Include CDA author IHE DYNAMIC 2.16.840.1.113883.10.12.103 Include CDA dataEnterer DYNAMIC 1.3.6.1.4.1.19376.1.8.1.4.6 Containment CDA Informant(Header&Body) APSR2 (2.0) DYNAMIC 2.16.840.1.113883.10.12.104 Include CDA custodian DYNAMIC 1.3.6.1.4.1.19376.1.3.3.1.4 Include XD-LAB Information Recipient (2008) DYNAMIC 2.16.840.1.113883.10.12.106 Include CDA legalAuthenticator DYNAMIC 1.3.6.1.4.1.19376.1.8.1.4.3 Include CDA authenticator IHE DYNAMIC 1.3.6.1.4.1.19376.1.3.3.1.6 Include Ordering Provider (2008) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.4.1 Include CDA Participant Specimen Collector DYNAMIC 1.3.6.1.4.1.19376.1.3.3.1.7 Containment Laboratory Performer (2008) DYNAMIC 2.16.840.1.113883.10.12.113 Include CDA componentOf DYNAMIC 1.3.6.1.4.1.19376.1.8.1.2.1 Containment Clinical Information Section (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.2.2 Containment Intraoperative Observation Section (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.2.3 Containment Macroscopic Observation Section (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.2.4 Containment Microscopic Observation Section (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.3.10.3.1 Containment Additional Specified Observation Section (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.2.5 Containment Diagnostic Conclusion Section (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.2.6 Containment Procedure Steps Section (2.0) DYNAMIC
Relationship	Specialization: template 2.16.840.1.113883.10.12.1 (2005‑09‑07)
Example	example for use case #1 <ClinicalDocument xsi:schemaLocation="urn:hl7-org:v3 infrastructure/cda/CDA_extended.xsd">   <realmCode code="UV"/>  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>  <templateId root="1.3.6.1.4.1.19376.1.8.1.1.1"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_1" assigningAuthorityName="IHE PaLM Technical Committee"/>  <code code="11526-1" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology Study"/>  <title>Anatomic Pathology Structured Report - Breast Biopsy</title>  <effectiveTime value="201001041605-0500"/>  <confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25"/>  <languageCode code="en-US"/>  <setId root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008" assigningAuthorityName="IHE PaLM Technical Committee"/>  <versionNumber value="1"/>  <!-- Patient -->   <recordTarget>     <patientRole>       <id extension="0411886319605719371016" root="1.3.6.1.4.1.19376.1.8.9.2"/>      <addr use="HP">         <streetAddressLine>39 East Street</streetAddressLine>        <postalCode>69499</postalCode>        <city>Appleton</city>        <state>WI</state>        <country>United States</country>      </addr>      <telecom nullFlavor="NASK"/>      <patient>         <name>           <prefix>Miss</prefix>          <given>EVE</given>          <family qualifier="BR">ONEWOMAN</family>        </name>        <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>        <birthTime value="19710921"/>      </patient>    </patientRole>  </recordTarget>  <!-- one or more author(s) of the report, with authoring time -->   <author>     <templateId root="1.3.6.1.4.1.19376.1.8.1.4.2"/>    <time value="20100104131933-0500"/>    <assignedAuthor>       <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>      <addr nullFlavor="MSK"/>      <telecom value="tel:+33-602030499"/>      <assignedPerson>         <name>           <given>Marcel</given>          <family>Pathologist</family>          <suffix>Ph D</suffix>        </name>      </assignedPerson>      <representedOrganization>         <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>        <name>CANCER INSTITUTE</name>        <telecom nullFlavor="MSK"/>        <addr nullFlavor="MSK"/>      </representedOrganization>    </assignedAuthor>  </author>  <!-- one or more transcriptionists, with transcription time -->   <dataEnterer>     <time value="20100104131720-0500"/>    <assignedEntity>       <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="A32"/>      <addr nullFlavor="MSK"/>      <telecom nullFlavor="MSK"/>      <assignedPerson>         <name>           <given>Adeline</given>          <family>Medsecret</family>        </name>      </assignedPerson>    </assignedEntity>  </dataEnterer>  <informant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Body) APSR2' (dynamic), not used in use case #1 -->   </informant>  <!-- The unique custodian of this document is the sending pathology lab that will administer it (further updates, deprecation) -->   <custodian>     <assignedCustodian>       <representedCustodianOrganization>         <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>        <name>CANCER INSTITUTE</name>        <telecom use="PUB" value="0466666666"/>        <addr>           <streetAddressLine>38 Cramberry Street</streetAddressLine>          <postalCode>69499</postalCode>          <city>Appleton</city>          <state>WI</state>        </addr>      </representedCustodianOrganization>    </assignedCustodian>  </custodian>  <!-- One or more additional intended recipients (other than the ordering physician) -->   <informationRecipient>     <templateId root="1.3.6.1.4.1.19376.1.3.3.1.4"/>    <intendedRecipient>       <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="987"/>      <addr>         <streetAddressLine>1600 Clifton Road</streetAddressLine>        <city>Atlanta</city>        <state>GA</state>        <postalCode>30333</postalCode>      </addr>      <telecom value="tel:404-639-3535"/>      <informationRecipient>         <name>           <family>WOULDLIKETOKNOW</family>          <given>Thomas</given>        </name>      </informationRecipient>    </intendedRecipient>  </informationRecipient>  <!-- The unique legal authenticator: The person assuming the final responsibility of the report and signing it -->   <legalAuthenticator>     <time value="20100104152503-0500"/>    <signatureCode code="S"/>    <assignedEntity>       <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>      <assignedPerson>         <name>           <given>Marcel</given>          <family>Pathologist</family>        </name>      </assignedPerson>    </assignedEntity>  </legalAuthenticator>  <!-- Zero or more additional content validator(s): pathologists having validated some part of the report -->   <authenticator>     <templateId root="1.3.6.1.4.1.19376.1.8.1.4.3"/>    <time value="20100104142503-0500"/>    <signatureCode code="S"/>    <assignedEntity>       <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567898"/>      <addr nullFlavor="MSK"/>      <telecom nullFlavor="MSK"/>      <assignedPerson>         <name>           <given>Jonas</given>          <family>Jones</family>          <prefix>MD</prefix>        </name>      </assignedPerson>    </assignedEntity>  </authenticator>  <!-- The ordering physician -->   <participant typeCode="REF">     <templateId root="1.3.6.1.4.1.19376.1.3.3.1.6"/>    <time>       <high value="20091231"/>    </time>    <associatedEntity classCode="PROV">       <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567892"/>      <addr nullFlavor="NASK"/>      <telecom value="tel:0147150000" use="EC"/>      <associatedPerson>         <name>           <prefix>Doctor</prefix>          <given>Eva</given>          <family>Surgeon</family>          <suffix>Ph D</suffix>        </name>      </associatedPerson>    </associatedEntity>  </participant>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.1 'CDA participant specimen collector' (dynamic) 0..* R, not used in use case #1 -->   <!-- Identification of the order, extension is Order-ID -->   <inFulfillmentOf>     <order>       <id root="1.3.6.1.4.1.19376.1.8.9.8" extension="12345"/>    </order>  </inFulfillmentOf>  <!-- Documented act(s): The pathology examination procedure, extension is Accession number -->   <documentationOf>     <serviceEvent>       <id root="1.3.6.1.4.1.19376.1.8.9.9" extension="A7102400008"/>      <code code="371528001" displayName="Pathology report (record artifact)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>      <lab:statusCode code="completed"/>      <effectiveTime>         <!-- Start: Date&time of reception of this order and the attached specimens -->         <low value="200912300922-0500"/>        <!-- End -->         <high value="201001041605-0500"/>      </effectiveTime>      <!-- Performing laboratory -->       <performer typeCode="PRF">         <templateId root="1.3.6.1.4.1.19376.1.3.3.1.7"/>        <time>           <high value="201001041605-0500"/>        </time>        <assignedEntity>           <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>          <representedOrganization>             <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>            <name>CANCER INSTITUTE</name>            <telecom nullFlavor="MSK"/>            <addr nullFlavor="MSK"/>          </representedOrganization>        </assignedEntity>      </performer>    </serviceEvent>  </documentationOf>  <!-- include template 1.3.6.1.4.1.19376.1.3.1.9999.10.9.16 'RelatedDocument Parent Document' (dynamic) 0..1 R, not used in use case #1 -->   <!-- Patient encounter: The patient stay in the hospital where the surgery was performed -->   <componentOf>     <encompassingEncounter>       <id root="1.3.6.1.4.1.19376.1.8.9.7" extension="234567890"/>      <code code="ACUTE" displayName="inpatient acute"/>      <effectiveTime>         <high value="2201001040735-0500"/>      </effectiveTime>      <location typeCode="LOC">         <healthCareFacility classCode="SDLOC">           <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="11223344"/>          <serviceProviderOrganization classCode="ORG" determinerCode="INSTANCE">             <name>Surgery theater</name>            <asOrganizationPartOf>               <wholeOrganization>                 <name>CANCER INSTITUTE</name>              </wholeOrganization>            </asOrganizationPartOf>          </serviceProviderOrganization>        </healthCareFacility>      </location>    </encompassingEncounter>  </componentOf>  <!-- Structured body -->   <component typeCode="COMP" contextConductionInd="true">     <structuredBody classCode="DOCBODY" moodCode="EVN">       <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.1 'Clinical Information Section' (dynamic) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.2 'Intraoperative Observation Section' (dynamic) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.3 'Macroscopic Observation Section' (dynamic) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.4 'Microscopic Observation Section' (dynamic) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.3.10.3.1 'Additionally Specified Observation Section' (dynamic) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.5 'Diagnostic Conclusion Section' (dynamic) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.6 'Procedure Steps Section' (dynamic) -->       </component>    </structuredBody>  </component></ClinicalDocument>
Item DT Card Conf Description Label hl7:ClinicalDocument 1 … 1 M PaLM…dule @classCode cs 1 … 1 F DOCCLIN @moodCode cs 1 … 1 F EVN hl7:templateId II 1 … 1 M This element is identifying the set of constraints applied to the CDA R2 standard by this IHE specification of a AP report. The following templateId SHALL be present and valued as follows to indicate compliance with the APSR 2.0 content module specification. PaLM…dule @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.1.1 hl7:realmCode CS CWE 1 … 1 M This element SHALL be present and is valued from the RealmOfUse [2.16.840.1.113883.1.11.11050] subset, within the VocabularyDomainQualifier value set. In the international context of this profile used as it is without any further extension, the realm code SHALL be <realmCode code="UV"/> (universal). Whenever a national extension has been defined and is used, the realm code SHALL identify this national extension. PaLM…dule hl7:typeId II 1 … 1 M This element is a technology-neutral explicit reference to the standard CDA R2. It SHALL be present and valued as follows: ClinicalDocument/typeId@root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models); ClinicalDocument.typeId@extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description). PaLM…dule @root uid 1 … 1 F 2.16.840.1.113883.1.3 @extension st 1 … 1 F POCD_HD000040 hl7:id II 1 … 1 M ClinicalDocument/Id SHALL be present. It represents the unique instance identifier of the clinical document. The combination of the root and extension attributes SHALL provide a globally unique identifier, in accordance with CDA R2, without further constraints. PaLM…dule @root uid 1 … 1 R Here the OID for PAT exemplary instances, in practice the OID of the LIS @extension st 1 … 1 R Here a hypothetical document ID, most often derived from the accession number   Constraint A report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report. The unique id of the current revision of the report is carried by the id element, and is composed of  id@root, which SHALL be an OID, and optionally id@extension, which can be any string so that the concatenation of the two attributes root and extension provide a globally unique id, which identifies this release of the report.    Example Report ID from use case #1 <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_1" assigningAuthorityName="IHE PaLM Technical Committee"/> hl7:code CE CNE 1 … 1 M ClinicalDocument/code SHALL be present. The document type of this content module is always <code code="11526-1" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology Study" codeSystemName="LOINC"/> PaLM…dule @code CONF 1 … 1 F 11526-1 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) @codeSystemName 1 … 1 F LOINC @displayName 1 … 1 F Pathology Study hl7:title ST 1 … 1 M The APSR <title> SHALL be present. It is the local translation of the code@displayName. PaLM…dule   CONF element content shall be "Anatomic Pathology Structured Report"   Example Report title from use case #1 <title>ANATOMIC PATHOLOGY REPORT - BREAST BIOPSY</title> hl7:effectiveTime TS 1 … 1 M ClinicalDocument/effectiveTime SHALL be present. It contains the creation date & time of the laboratory report as an electronic document. In case this is a new revision replacing a previous version (identified in parentDocument), this is the date & time of the new revision. PaLM…dule hl7:confidentialityCode CE CNE 1 … 1 M ClinicalDocument/confidentialityCode SHALL be present in accordance with the HL7 CDA R2 standard. PaLM…dule   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC) hl7:language​Code CS CNE 1 … 1 M ClinicalDocument/languageCode SHALL be present in accordance with the HL7 CDA R2 standard. PaLM…dule   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC) hl7:setId II 1 … 1 M ClinicalDocument/setId SHALL be present to enable further updates of the clinical document. It is an identifier that is common across all revisions of this AP report. PaLM…dule @root uid 1 … 1 R @extension st 1 … 1 R   Constraint A report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report. The setId element provides a globally unique identifier that is common across all successive revisions of the report. This identifier is similarly composed of setId@root, which SHALL be an OID, and optionally setId@extension.    Example Report set ID from use case #1 <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008" assigningAuthorityName="IHE PaLM Technical Committee"/> hl7:versionNumber INT 0 … 1 R ClinicalDocument/versionNumber MAY be present. As requested by the CDA standard, it is an integer value used as versioning. PaLM…dule @value int 1 … 1 R   Constraint A report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report. The version number of the current revision of the report is a positive integer (1, 2 …) provided in the versionNumber element.   Example Report version number for use case #1 <versionNumber value="1"/> Included 1 … 1 M from 1.3.6.1.4.1.19376.1.3.3.1.1 Human Patient (DYNAMIC) The Patient. The anatomic pathology report is related to ONE SINGLE patient.  A patient SHALL be identified with at least one unique patientRole/Id.   The patient address and telecom SHALL be provided (or null flavored).   The patient identity SHALL provide AT LEASTthe patient full name, sex and date/time of birth.  hl7:recordTarget 1 … 1 M PaLM…dule hl7:patientRole 1 … 1 R PaLM…dule hl7:id II 1 … * R PaLM…dule hl7:addr AD 1 … * All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. PaLM…dule hl7:telecom TEL 1 … * All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. PaLM…dule hl7:patient 1 … 1 PaLM…dule hl7:id II 0 … 1 PaLM…dule hl7:name PN 1 … * PaLM…dule hl7:administrative​Gender​Code CE 1 … 1 R PaLM…dule hl7:birthTime TS 1 … 1 R PaLM…dule Included 1 … * M from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (DYNAMIC) The Author Content Module represents an author of the report. This element is repeatable. The sub-element  author/time  carries the date/time of the authoring action.  At least one ClinicalDocument/author SHALL be present with a time in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. The author/time element carries the date&time the AP report was produced. The AP report can be authored by a software system or by a person or by both. Source: PaLM Suppl.APSR 2.0‑3: 6.3.6.2 hl7:author 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @typeCode cs 1 … 1 F AUT   Example author is a person <author typeCode="AUT" contextControlCode="OP">   <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">     <!-- ... -->   </assignedAuthor></author> hl7:templateId 1 … 1 M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.4.2 hl7:time TS 1 … 1 M The authoring time is the date & time that this author contributed to the document. It SHALL be provided. PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assignedAuthor 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F ASSIGNED hl7:id II 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Choice 1 … 1 The author is either an assigned person or an authoring device. Elements to choose from: hl7:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Included 0 … * from 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC) The name(s) SHALL be given. @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:softwareName SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:represented​Organization 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author   Example represented organization for author as a device <representedOrganization classCode="ORG" determinerCode="INSTANCE">   <name>     <!-- ... -->   </name></representedOrganization> Included 0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given. @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:asOrganizationPartOf 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F PART hl7:id II 0 … * R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @codeSystem CONF 1 … 1 F 2.16.840.1.113883.5.111 (Role Code) hl7:statusCode CS 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC) hl7:effectiveTime IVL_TS 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:wholeOrganization 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Included 0 … * R from 2.16.840.1.113883.10.12.103 CDA dataEnterer (DYNAMIC) Transcriptionist hl7:dataEnterer 0 … * R PaLM…dule @typeCode 0 … 1 F ENT @context​Control​Code 0 … 1 F OP hl7:time TS 0 … 1 PaLM…dule hl7:assignedEntity 1 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) PaLM…dule hl7:informant 0 … * R Zero or more informant MAY be mentioned in the header of the report. An informant is either an  assignedEntity  (a professional participating to the healthcare process, and who was assigned a defined role in that process) or a  relatedEntity  (a person who knows the patient and has provided relevant information concerning the patient). Hence the condition is either  assignedEntity  is present or  relatedEntity  is present. These two elements are defined in the content module “Informant”. Source: PaLM 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…dule Included 1 … 1 M from 2.16.840.1.113883.10.12.104 CDA custodian (DYNAMIC) ClinicalDocument/custodian SHALL be present with an id in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. It represents the organization that is in charge of maintaining the AP report. hl7:custodian 1 … 1 M PaLM…dule @typeCode 0 … 1 F CST hl7:assignedCustodian 1 … 1 PaLM…dule @classCode 0 … 1 F ASSIGNED hl7:represented​Custodian​Organization 1 … 1 PaLM…dule @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 1 … * M PaLM…dule hl7:name ON 0 … 1 PaLM…dule hl7:telecom TEL 0 … 1 PaLM…dule hl7:addr AD 0 … 1 PaLM…dule Included 0 … * R from 1.3.6.1.4.1.19376.1.3.3.1.4 XD-LAB Information Recipient (DYNAMIC) The Intended Recipient Content Module represents a healthcare provider,  other than the ordering physician, expecting to receive a copy of the report. This repeatable element informationRecipient of the CDA header is used to list the intended recipients who were known at the time the report was created and issued.  Source: PaLM TF-3: 6.3.2.14 hl7:information​Recipient 0 … * R PaLM…dule hl7:templateId II 1 … 1 M PaLM…dule @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.3.1.4 hl7:intended​Recipient 1 … 1 R PaLM…dule hl7:id II 0 … * R PaLM…dule hl7:addr AD 1 … * PaLM…dule hl7:telecom TEL 1 … * PaLM…dule hl7:information​Recipient 0 … 1 Contains 1.3.6.1.4.1.19376.1.3.10.9.18 PlayingEntity or person with Name (DYNAMIC) PaLM…dule hl7:received​Organization 0 … 1 Contains 1.3.6.1.4.1.19376.1.3.10.9.13 Organization with Name, Addr, Telecom (DYNAMIC) PaLM…dule Included 1 … 1 M from 2.16.840.1.113883.10.12.106 CDA legalAuthenticator (DYNAMIC) The Legal authenticator Content Module describes a pathologist having verified the content of the report, using the element legalAuthenticator. The report SHALL have one legal Authenticator Source: PaLM TF-3: 6.3.2.15 hl7:legalAuthenticator 1 … 1 M PaLM…dule @typeCode 0 … 1 F LA @context​Control​Code 0 … 1 F OP hl7:time TS 1 … 1 R PaLM…dule hl7:signatureCode CS 1 … 1 R PaLM…dule   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC) hl7:assignedEntity 1 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) PaLM…dule Included 0 … * R from 1.3.6.1.4.1.19376.1.8.1.4.3 CDA authenticator IHE (DYNAMIC) The Content validator Content Module describes a pathologist having verified the content of the report, using the element authenticator. This element authenticator is used when the pathologist having verified the content of the report is distinct from the pathologist assuming the legal responsibility for this report, described in the legalAuthenticator element. The report MAY have zero or more Content Validators. Source: PaLM Suppl. APSR 2.0-3: 6.3.6.3 hl7:authenticator 0 … * R PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator @typeCode cs 1 … 1 F AUTHEN hl7:templateId 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.4.3 hl7:time TS 1 … 1 R Time of validation PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator hl7:assignedEntity 0 … 1 C AssignedPerson SHALL be given with name, representedOrganization MAY be given. Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator Included 1 … 1 R from 1.3.6.1.4.1.19376.1.3.3.1.6 Ordering Provider (DYNAMIC) The Ordering Provider Content Module represents the physician who has submitted the specimen examination order to the anatomic pathology laboratory. As specified in PaLM TF-3, this physician is represented in the CDA header as a participant element with the typeCode attribute valued “REF”. The sub-element participant/time carries the date/time of issuance of the order. Source: PaLM TF-3: 6.3.2.17 hl7:participant 1 … 1 R Referral Ordering Physician PaLM…dule @typeCode cs 1 … 1 F REF hl7:templateId II 1 … 1 PaLM…dule @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.3.1.6 hl7:time IVL_TS 1 … 1 R This element represents the date and time the order was placed. Time MAY be present. PaLM…dule hl7:associated​Entity 1 … 1 PaLM…dule hl7:addr AD 1 … * R The address of this person (referral ordering physician) SHALL be present. PaLM…dule hl7:telecom TEL.AT 1 … * R The telecom of this person (referral ordering physician) SHALL be present. PaLM…dule   Schematron assert role  error     test not(hl7:assigned​Person) or hl7:assigned​Person/hl7:name     Message The <name> sub-element SHALL be present when <assignedPerson> present.   hl7:associated​Person 0 … 1 R PaLM…dule hl7:scoping​Organization 0 … 1 PaLM…dule Included 0 … * R from 1.3.6.1.4.1.19376.1.8.1.4.1 CDA Participant Specimen Collector (DYNAMIC) The Specimen Collector Content Module is only used in case a specimen provided as input to the AP act documented in this report, was collected by a different party than the ordering physician. In that case, this specimen collector is represented in the CDA header as a participant element with the typeCode attribute valued “DIST” and the sub-element participant/time carries the time period of the specimen collection. Source: PAT TF-3: 6.2.6.1 hl7:participant 0 … * R The Specimen Collector Content Module is only used in case a specimen provided as input to the AP act documented in this report, was collected by a different party than the ordering physician. In that case, this specimen collector is represented in the CDA header as a participant element with the typeCode attribute valued “DIST” and the sub-element participant/time carries the time period of the specimen collection. PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector @typeCode cs 1 … 1 F DIST hl7:templateID II 1 … 1 M PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.4.1 hl7:time IVL_TS 1 … 1 M Specimen collection time The specimen collection time is an interval, which may be reduced to a point in time (see usage of data type IVL_TS). PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector hl7:associated​Entity 0 … 1 R At least one of the two elements associatedPerson and scopingOrganization must be present. Both may be present.  PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector @classCode cs 1 … 1 F PROV hl7:id II 1 … * R PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector hl7:addr AD 1 … * R PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector hl7:telecom TEL.AT 1 … * R PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector hl7:associated​Person 0 … * C Person who collected the specimen. Only full name(s) SHALL be given. Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC) PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector hl7:scoping​Organization 0 … 1 C Organization taking care for specimen collection. Identifiers, name, telecom, and address SHOULD be given. Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector hl7:inFulfillmentOf 0 … 1 R The inFulfillmentOf/order element MAY be present. It represents the Placer Order or the Placer Group that was fulfilled, the Id of which is carried by inFulfillmentOf/order/id. PaLM…dule @typeCode cs 1 … 1 F FLFS hl7:order 1 … 1 M PaLM…dule @classCode cs 1 … 1 F ACT @moodCode cs 1 … 1 F RQO hl7:id II 1 … * R Placer order group ID or Placer order ID PaLM…dule hl7:documentationOf 1 … 1 M Documented act. PaLM…dule @typeCode cs 1 … 1 F DOC hl7:serviceEvent 1 … 1 M The AP report is documenting a service (documentationOf/serviceEvent) performed by a surgical pathology laboratory. The Laboratory Performer Content Module represents this laboratory, and is fully described in the sub-element documentationOf/serviceEvent/performer. In case more than one laboratory contributed to a service, only the primary laboratory is in the CDA header, attached to the serviceEvent element, and the other (secondary) laboratories are described only in the sections of the report that they contributed to, in the body of the report. Source: PaLM TF3: 6.3.2.19 PaLM…dule @classCode cs 1 … 1 R @moodCode cs 1 … 1 R hl7:id II 1 … * M ID of the Act, i.e. Accession number PaLM…dule hl7:code CE CWE 0 … 1 R PaLM…dule   CONF @code shall be "PATREPE" @codeSystem shall be "2.16.840.1.113883.5.4" @codeSystemName shall be "HL7 ActCode" @displayName shall be "pathology report entry task" or @code shall be "371528001" @codeSystem shall be "2.16.840.1.113883.6.96" @codeSystemName shall be "SCT" @displayName shall be "Pathology report (record artifact)" hl7:effectiveTime IVL_TS 0 … 1 R Use of sub element documentationOf/serviceEvent/effectiveTime to document the time boundaries of events in the document is appropriate. PaLM…dule ihe-lab:statusCode CS CNE 0 … 1 R This APSR Content Module can express both final and non-final reports. To distinguish between the two, the statusCode element has been added to the documentationOf/serviceEvent element. A non-final report is a report documenting a serviceEvent, which is in the status "active". This sub-element serviceEvent/statusCode is optional. When it is not present the serviceEvent is assumed to be in the status "completed". The statusCode below documentationOf/serviceEvent is an extension to the CDA R2 standard, added by PaLM TF-3 to distinguish a preliminary report (statusCode@code="active") from a final report (statusCode@code="completed").  The statusCode sub element is  further described in section A.3 of PaLM TF-3. This sub-element is required. When it is not there, the documented Act is assumed to be completed and the report is assumed to be a final report. This extension to the standard is protected by a dedicated namespace associated in the ClinicalDocument element to the prefix lab: <Clinical Document  xmlns:lab="urn:oid:1.3.6.1.4.1.19376.1.3.2" … >  Source: PaLM TF3: 6.3.2.19 PaLM…dule   Constraint The statusCode@code="completed" is only applicable, if ALL content modules of the Clinical Document have the statusCode@code="completed", too, or have the statusCode@code="aborted".   CONF The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.4 ActStatusActiveCompleted (DYNAMIC)   Schematron assert role  error     test hl7:serviceEvent/ihe-lab:statusCode[@code='completed']     Message Status code of all Content Modules SHALL be "complete" or "aborted"   hl7:performer 0 … * R Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC) PaLM…dule hl7:relatedDocument 0 … 1 R ClinicalDocument/relatedDocument/parentDocument This element SHALL be present in case of an update replacement of a previous report. In this case relatedDocument@typeCode attribute SHALL be valued "RPLC", the new report replacing the parent one. Note 1: A non-final laboratory report published in an XDS infrastructure will likely be replaced afterwards by the final report. When this event occurs, the Content Creator Actor SHALL apply the following rules: ClinicalDocument/setId SHALL have the same value in the new report as in the replaced report. ClinicalDocument/versionNumber SHALL be incremented in the replacing report (i.e., the final one). ClinicalDocument/relatedDocument@typeCode attribute SHALL be valued ”RPLC” ClinicalDocument/relatedDocument/parentDocument/id in the new report SHALL be equal to ClinicalDocument/ id of the replaced document. The Document Source Actor SHALL apply the following rules on XDSDocumentEntry metadata: The final report SHALL be associated with the previously published one, using RPLC relationship and the previous report SHALL be “Deprecated” as described in ITI TF-2:4.1.6.1. Note 2: A non-final report can also be replaced by a more recent, albeit still non-final report. The rules above also apply in this case. Note 3: A final report can also be replaced by a corrective final report. The rules above also apply in this case. PaLM…dule @typeCode cs 1 … 1 F RPLC   relatedDocument@typeCode attribute SHALL be valued "RPLC" hl7:parentDocument ANY 1 … 1 M PaLM…dule hl7:id II 1 … 1 M SHALL be equal to ClinicalDocument/ id of the replaced document. PaLM…dule hl7:setId II 1 … 1 M SHALL have the same value in the new report as in the replaced report. PaLM…dule hl7:versionNumber INT 0 … 1 R SHALL have the same value as in the replaced report (when provided there). PaLM…dule Included 0 … 1 R from 2.16.840.1.113883.10.12.113 CDA componentOf (DYNAMIC) The ClinicalDocument/componentOf/encompassingEncounter element MAY be present. It describes the encounter during which the reported AP observations were ordered. When present the encounter SHALL: be identified with an id element: encompassingEncounter/id The encounter SHALL have an effective time that represents the time interval (possibly still running, e.g., an inpatient current stay) of the encounter or a point in time at which the encounter took place (e.g., an outpatient consultation): encompassingEncounter/ effectiveTime The encounter MAY provide any number of encounter participants (encompassingEncounter/encounterParticipant/assignedEntity). When present, encounter participants SHALL be in accordance with the HL7 CDA R2 standard with a time and further constrained by this specification to require the presence of name, addr and telecom. Additionally, the encounter participant SHALL have a typeCode with one the values selected from the x_EncounterParticipant domain: The encounter MAY precise the patient location during this encounter. This is the healthcare facility in which the patient was located when the reported AP observations were ordered: encompassingEncounter/location/healthCareFacility. This healthcare facility can be represented as a physical place (e.g., room, floor, building, office) or as an organization (e.g., service, department, team) or both: healthCareFacility/location, healthCareFacility/serviceProviderOrganization. hl7:componentOf 0 … 1 R PaLM…dule @typeCode 0 … 1 F COMP hl7:encompassing​Encounter 1 … 1 PaLM…dule @classCode 0 … 1 F ENC @moodCode 0 … 1 F EVN hl7:id II 0 … * PaLM…dule hl7:code CE 0 … 1 PaLM…dule   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC) hl7:effectiveTime IVL_TS 1 … 1 R PaLM…dule hl7:discharge​Disposition​Code CE 0 … 1 PaLM…dule   CONF shall be drawn from concept domain "EncounterDischargeDisposition" hl7:responsible​Party 0 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) PaLM…dule @typeCode 0 … 1 F RESP hl7:encounterParticipant 0 … * PaLM…dule @typeCode cs 1 … 1 R   CONF The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC) hl7:time IVL_TS 0 … 1 PaLM…dule hl7:assignedEntity 1 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) PaLM…dule hl7:location 0 … 1 PaLM…dule @typeCode 0 … 1 F LOC hl7:health​Care​Facility 1 … 1 PaLM…dule @classCode 0 … 1 F SDLOC hl7:id II 0 … * PaLM…dule hl7:code CE 0 … 1 PaLM…dule   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC) hl7:location 0 … 1 Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC) PaLM…dule hl7:service​Provider​Organization 0 … 1 Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) PaLM…dule hl7:component 1 … 1 R Body of the CDA Clinical document PaLM…dule @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:structuredBody 1 … 1 R PaLM…dule @classCode cs 1 … 1 F DOCBODY @moodCode cs 1 … 1 F EVN hl7:component 0 … 1 R The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, clinical laboratory data, specimen(s) description, collection procedure, reason for anatomic pathology procedure. Contains 1.3.6.1.4.1.19376.1.8.1.2.1 Clinical Information Section (DYNAMIC) PaLM…dule @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R The Intraoperative Observation section contains an intraoperative diagnosis for each specimen examined, the specimen identification and description, intraoperative observation procedure description (frozen section, gross examination, intraoperative cytology) and derived specimen dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, and electron microscopy). Contains 1.3.6.1.4.1.19376.1.8.1.2.2 Intraoperative Observation Section (DYNAMIC) PaLM…dule @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R The Macroscopic Observation section contains the description of the specimen received or obtained by the laboratory (specimen type and state), the gross observation, links to gross images, if taken, processing information and tissue disposition (representative sampling and tissue submitted for additional studies or sent to biorepository. Contains 1.3.6.1.4.1.19376.1.8.1.2.3 Macroscopic Observation Section (DYNAMIC) PaLM…dule @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R The Microscopic Observation section contains optionally the histopathologic findings of the case and many laboratories use this section to record the results of histochemical and immunohistochemical stains. Contains 1.3.6.1.4.1.19376.1.8.1.2.4 Microscopic Observation Section (DYNAMIC) PaLM…dule @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R The Additional Specific Observation section includes additional pathologic finding(s) and the results of ancillary study(ies) with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken.  Contains 1.3.6.1.4.1.19376.1.3.10.3.1 Additional Specified Observation Section (DYNAMIC) PaLM…dule @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 1 … 1 M The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist. Contains 1.3.6.1.4.1.19376.1.8.1.2.5 Diagnostic Conclusion Section (DYNAMIC) PaLM…dule where [not(@nullFlavor)] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R The Procedure steps section contains the description of tissue dissection: representative specimens and derived specimens dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, electron microscopy, etc.) or biorepository. Contains 1.3.6.1.4.1.19376.1.8.1.2.6 Procedure Steps Section (DYNAMIC) PaLM…dule @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true