| Item | DT | Card | Conf | Description | Label |
|---|
| | 0 … * | R | | PaLMeps |
 | @classCode
|
| cs | 1 … 1 | F | PROC |
| @moodCode
|
| cs | 1 … 1 | F | EVN |
| hl7:templateId
|
| II | 1 … 1 | R | | PaLMeps |
 | | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.3.10.4.1 |
| hl7:id
|
| II | 0 … * | R | Procedure ID, coming from the LIS.
May be the target (referenced) ID for the child procedure. | PaLMeps |
| hl7:code
|
| CD CWE | 1 … 1 | M | Coded procedure | PaLMeps |
| | Constraint | for specimen collection procedure codes for targetSite or SNOMED CT have to be used, for specimen processing (down step the procedures) SNOMED CT is preferred, DICOM could be used if available
|
| | CONF | | The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.10 Specimen Collection and Processing (DYNAMIC) |
|
| | Example | for use case #1, specimen collection <code code="122548005" codeSystem="2.16.840.1.113883.6.96" displayName="Biopsy of breast (procedure)" codeSystemName="SNOMED-CT"/> |
| | Example | for use case #1, grossing & embedding <code code="40923002" codeSystem="2.16.840.1.113883.6.96" displayName="Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)"/> |
| | Example | for use case #1, sectioning & immunostaining <code code="117617002" codeSystem="2.16.840.1.113883.6.96" displayName="Immunohistochemistry procedure (procedure)"/> |
| | hl7:qualifier
|
| CR CWE | 0 … * | C | Qualifier for staining or other procedures which don´t have values in the vocabulary used.
| PaLMeps |
| | Constraint | Used only in staining and other procedures without values in SCT or LOINC or DICOM vocabulary, e.g. immune stains
|
| | Example | for use case #1, grossing & embedding <qualifier>
<name code="246355002" displayName="Supporting structure (attribute)" codeSystem="2.16.840.1.113883.6.96"/> <value code="702941008" displayName="Paraffin embedding (qualifier value)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/></qualifier> |
| | Example | for use case #1, Estrogen receptor staining <qualifier>
<name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/> <value code="23307004" displayName="Estrogen receptor (substance)" codeSystem="2.16.840.1.113883.6.96"/></qualifier> |
| | Example | for use case #1, ISH Her-2-neu staining <qualifier>
<name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/> <value code="164870" displayName="ONCOGENE ERBB2" codeSystem="2.16.840.1.113883.6.174" codeSystemName="OMIM"/></qualifier> |
| CV CWE | 1 … 1 | R | | PaLMeps |
| cs | 0 … 1 | F | 246094008_or_246355002 |
| oid | 0 … 1 | F | 2.16.840.1.113883.6.96 |
| st | 0 … 1 | F | Component investigated (attribute) or Supporting structure (attribute) |
| CD CWE | 1 … 1 | R | | PaLMeps |
| cs | 1 … 1 | R | |
| | CONF | | @code shall be "<<105590001 | Substance (substance) |" | | @codeSystem shall be "2.16.840.1.113883.6.96" | | @codeSystemName shall be "SNOMED-CT" | | @displayName shall be "values from substance axis, e.g. Estrogen receptor" | | or | | @code shall be "values from G axis" | | @codeSystem shall be "2.16.840.1.113883.6.174" | | @codeSystemName shall be "OMIM" | | @displayName shall be "values from G axis, e.g. erb-b2" | | or | | @code shall be "<<272394005 | Technique (qualifier value) |" | | @codeSystem shall be "2.16.840.1.113883.6.96" | | @codeSystemName shall be "SNOMED-CT" | | @displayName shall be "values from technique axis, e.g. Paraffin embedded (qualifier)" |
|
| hl7:text
|
| ED | 0 … 1 | R | | PaLMeps |
| | Example | specimen collection procedure <text>ULTRASOUND GUIDED NEEDLE CORE BIOPSY</text> |
| | Example | specimen processing procedure <text>CUTTING A SLIDE FROM A PARAFFIN BLOCK</text> |
| hl7:statusCode
|
| CS CNE | 0 … 1 | R | | PaLMeps |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC) |
|
| hl7:effectiveTime
|
| IVL_TS | 0 … 1 | R | | PaLMeps |
| hl7:approachSiteCode
|
| CD CWE | 0 … 1 | R | Approach site in specimen collection | PaLMeps |
| | @code
|
| CONF | 0 … 1 | F | any_code |
| | @codeSystem
|
| 0 … 1 | F | 2.16.840.1.113883.5.1052 (Act Site) |
| | @codeSystemName
|
| 0 … 1 | F | any_code |
| | @displayName
|
| 0 … 1 | F | ActSite |
| hl7:targetSiteCode
|
| CD CWE | 0 … 1 | R | Target site in body or relative parent relationship in case of specimen processing | PaLMeps |
| | CONF | | The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.9 Procedure Site (DYNAMIC) | | or | | @code shall be "<<123037004 | Body structure (body structure) |" | | @codeSystem shall be "2.16.840.1.113883.6.96" | | @codeSystemName shall be "SCT" | | @displayName shall be "all children of Body structure (body structure)" | | or | | @code shall be "any_code" | | @codeSystem shall be "2.16.840.1.113883.5.1052" | | @codeSystemName shall be "ActSite" | | @displayName shall be "any_code" |
|
| | Example | for use case #1, specimen collection <targetSiteCode code="110497008" displayName="Lower outer quadrant of right breast (body structure)" codeSystem="2.16.840.1.113883.6.96"/> |
| | Example | for use case #1, grossing & embedding <targetSiteCode code="309050000" displayName="Body substance sample" codeSystem="2.16.840.1.113883.6.96"/> |
| | hl7:qualifier
|
| CR CWE | 0 … * | C | optional qualifiers for specifying body structures or / and laterality | PaLMeps |
| | Example | for use case #1, (optional) specification of body structure for specimen collection <qualifier>
<name code="118169006" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen source topography (attribute)" codeSystemName="SNOMED-CT"/> <value code="255495000" codeSystem="2.16.840.1.113883.6.96" displayName="Right lower quadrant (qualifier value)" codeSystemName="SNOMED-CT"/></qualifier> |
| CV CWE | 1 … 1 | R | | PaLMeps |
| st | 0 … 1 | F | Specimen source topography |
| oid | 1 … 1 | F | 2.16.840.1.113883.6.96 |
| cs | 1 … 1 | F | 118169006 |
| CD CWE | 0 … * | R | | PaLMeps |
| CONF | 0 … 1 | | @code shall be out of choice:- <<272099008
- Descriptor (qualifier value)
|
| 0 … 1 | F | 2.16.840.1.113883.6.96 (SNOMED Clinical Terms) |
| 0 … 1 | F | SCT |
| 0 … 1 | F | all children of "Descriptor, qualifier values", e.g. right lower quadrantt |
| hl7:methodCode
|
| CD CWE | 0 … * | R | Identifies the technique used to perform a procedure
| PaLMeps |
| | @codeSystem
|
| cs | 1 … 1 | F | 2.16.840.1.113883.5.1065 |
| Included | 0 … 1 | R | from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC)
Parent specimen with parent ID |
| | Example | for use case #1, parent specimen ID in grossing & embedding <specimen typeCode="SPC">
<specimenRole classCode="SPEC">
<!-- Parent specimen ID -->
<id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008"/> </specimenRole></specimen> |
| hl7:specimen
|
| | 0 … 1 | R | Required in XD-LAB when more than one specimen is documented at this level. Always required in APSR.
| PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified |
| | @typeCode
|
| cs | 0 … 1 | F | SPC |
| | hl7:specimenRole
|
| | 1 … 1 | M | | PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified |
| cs | 0 … 1 | F | SPEC |
| II | 1 … 1 | R | Specimen ID, coming from the LIS | PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified |
| hl7:performer
|
| | 0 … 1 | R | Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC) | PaLMeps |
| hl7:author
|
| | 0 … * | C | Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (DYNAMIC) | PaLMeps |
| hl7:participant
|
| | 1 … * | M | One or more specimen (with additives), which participates as product of the procedure
Contains 1.3.6.1.4.1.19376.1.3.10.9.44 CDA Participant (Body) Procedure Steps APSR2 (DYNAMIC) | PaLMeps |
| where [not(@nullFlavor)] |
| |
| hl7:entryRelationship
|
| | 0 … * | R | Artificial material (manufactured product) which containes the specimen
Contains 1.3.6.1.4.1.19376.1.3.10.9.22 CDA Supply Container APSR2 (DYNAMIC) | PaLMeps |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | Constraint | for manufactured product
classCode = MANU
for DrugOrOtherMaterial
classCode = MMAT
code from MaterialEntityClassType
|
| hl7:entryRelationship
|
| | 0 … 1 | R | Specimen arrival in Lab
Contains 1.3.6.1.4.1.19376.1.3.1.3 Specimen Received (DYNAMIC) | PaLMeps |
| where [hl7:act [hl7:code [(@code='SPRECEIVE' and @codeSystem='1.3.5.1.4.1.19376.1.5.3.2') or @nullFlavor]]] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| hl7:entryRelationship
|
| | 0 … * | R | Referencing mechanism to the ID of the child procedures, giving a lis of child procedure IDs
Contains 1.3.6.1.4.1.19376.1.3.10.4.1 Specimen Procedure Step (DYNAMIC) | PaLMeps |
| where [hl7:procedure [hl7:code [concat(@code,@codeSystem)=doc('include/voc-1.3.6.1.4.1.19376.1.3.11.10-DYNAMIC.xml')//valueSet [1]/conceptList/concept/concat(@code,@codeSystem)]]] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | REFR |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | Constraint | contains only ID of the child procedure, which is fully described in a dedicated entry further down in the Procedure step section. |
Draft
