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Version vom 2. Februar 2017, 13:46 Uhr

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Template TNMTObservation

Description

Template CDA Observation (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF)T-Observation:The following details are provided as qualifiers: clinical/phological Certainty Factor multiple tumors + multiplicity mi-Symbol Mucosa-level of infiltration Submucosa-level of infiltration

Actual version

Id1.3.6.1.4.1.19376.1.3.10.9.25Effective Date valid from 2014‑12‑02 15:54:17
StatusKyellow.png DraftVersion Label2.0
NameTNMTObservationDisplay NameTNM T-Observation
Description
Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF)


T-Observation:
The following details are provided as qualifiers:

  • clinical/phological
  • Certainty Factor
  • multiple tumors + multiplicity
  • mi-Symbol
  • Mucosa-level of infiltration
  • Submucosa-level of infiltration
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.25
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 2 templates, Uses 4 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.3.10.4.2ContainmentKyellow.png TNM Stage Observation (2.0)2014‑05‑13 15:45:13
1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)2016‑07‑08 11:22:58
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
RelationshipSpecialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 (2014‑05‑14 17:09:54)
Example
generated example
<observation negationInd="false" classCode="OBS" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.9.25"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="21899-0" codeSystem="2.16.840.1.113883.6.1"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20170712152936"/>  </effectiveTime>  <value xsi:type="CD" code="261663004" displayName="Tumor stage Ta (tumor staging)" codeSystem="2.16.840.1.113883.6.96">
    <qualifier>
      <name code="tnmCFactor" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="84068000" displayName="C1 - TNM certainty factor" codeSystem="2.16.840.1.113883.6.96"/>    </qualifier>    <qualifier>
      <name code="tnmCp" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="p" displayName="p" codeSystem="1.2.276.0.76.11.9"/>    </qualifier>    <qualifier>
      <name code="tnmMultiplicity" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="m" displayName="(m)" codeSystem="2.16.840.1.113883.15.6"/>    </qualifier>    <qualifier>
      <name code="tnmMucosaSymbol" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="m1" displayName="m1" codeSystem="2.16.840.1.113883.15.6"/>    </qualifier>    <qualifier>
      <name code="tnmSubmucosaSymbol" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="sm1" displayName="sm1" codeSystem="2.16.840.1.113883.15.6"/>    </qualifier>  </value>  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->
  </performer>  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->
  </author>  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->
  </informant>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 1..* M -->
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … 1R(TNM...ion)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1M(TNM...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.9.25
Treetree.pnghl7:id
II0 … *R(TNM...ion)
Treetree.pnghl7:code
CE (extensible)1 … 1Mthe observation can be indicated either by a LOINC or Snomed code.
(TNM...ion)
 CONF
@code shall be "21899-0"
@codeSystem shall be "2.16.840.1.113883.6.1"
@codeSystemName shall be "LOINC"
or
@code shall be "78873005"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "Snomed CT"
@displayName shall be "T category (observable entity)"
Treetree.pnghl7:text
ED0 … 1R(TNM...ion)
Treetree.pnghl7:statusCode
CS (required)1 … 1M(TNM...ion)
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 (DYNAMIC)
Alert.pngError: Cannot find value set "1.3.6.1.4.1.19376.1.3.11.2"
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1M(TNM...ion)
Treetree.pnghl7:value
CD (extensible)1 … 1R(TNM...ion)
 CONF
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.12 UICC T category (SCT) (2014‑05‑13 15:52:43)
or
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.43 UICC T category (2017‑07‑07 15:06:39)
Treeblank.pngTreetree.pnghl7:qualifier
CR (extensible)0 … 1RC-Factor (Certainty)
(TNM...ion)
 Constraintin UICC/AJCC TNM 8th edition no longer used
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV (required)1 … 1M(TNM...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.276.0.76.3.1.131.1.5.1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1FtnmCFactor
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD (extensible)0 … 1R(TNM...ion)
 CONF
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.20 UICC C-Factor (SCT) (2015‑06‑22 15:47:55)
or
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.19 UICC C-Factor (2015‑11‑13 13:56:23)
Treeblank.pngTreetree.pnghl7:qualifier
CR (extensible)0 … 1Rhow is the T-value determined:
- clinically ("c")
-- ultrasound
-- CT
-- MR
- pathologically, postoperatively ("p")
(TNM...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV (required)1 … 1Mclinical or pathological (TNM...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.276.0.76.3.1.131.1.5.1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1FtnmCp
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD (extensible)0 … 1R(TNM...ion)
 Constraintin APSR only "p" allowed
 CONF
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.22 UICC clinical/pathological (2015‑11‑04 15:52:34)
Treeblank.pngTreetree.pnghl7:qualifier
CR (extensible)0 … 1RtnmMuliple :
multiple, simultaneous tumors in one organ;
here: a boolean indicator that there are multiple tumors  ("m") without any numbers
(TNM...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV (required)1 … 1Mcode for multiple tumors in one organ(TNM...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.276.0.76.3.1.131.1.5.1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1FtnmMultiplicity
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CV (extensible)0 … 1R(TNM...ion)
 CONF
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.37 UICC Multiplicity (2015‑11‑06 10:44:54)
Treeblank.pngTreetree.pnghl7:qualifier
CR (extensible)0 … 1Rlimited to mucosa
(TNM...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV (required)1 … 1M(TNM...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.276.0.76.3.1.131.1.5.1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1FtnmMucosaSymbol
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD (extensible)0 … 1R(TNM...ion)
 CONF
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.26 UICC Mucosa (2015‑11‑04 16:22:04)
Treeblank.pngTreetree.pnghl7:qualifier
CR (extensible)0 … 1Rlimited to mucosa and submucosa
(TNM...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV (required)1 … 1M(TNM...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.276.0.76.3.1.131.1.5.1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1FtnmSubmucosaSymbol
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD (extensible)0 … 1R(TNM...ion)
 CONF
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.27 UICC Submucosa (2015‑11‑04 16:23:24)
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 (2008‑08‑08)		(TNM...ion)
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
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 (2016‑06‑21 14:02:11)		(TNM...ion)
Treeblank.png where [hl7:author [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.2']]]
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 (2016‑07‑08 11:22:58)		(TNM...ion)
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.6']]
Included1 … *M from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
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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