1.3.6.1.4.1.19376.1.3.10.9.42

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Template AssessmentScoringSystemAPSR2.0

Description

Template CDA Observation (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF)

Actual version

Id	1.3.6.1.4.1.19376.1.3.10.9.42	Effective Date	valid from 2016‑10‑10 11:33:36
Status	Draft	Version Label	2.0
Name	AssessmentScoringSystemAPSR2.0	Display Name	Assessment Scoring System APSR 2.0
Description	Supportive Observation entry for describing a scoring system
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.42
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 2 templates, Uses 4 templates Used by as Name Version 1.3.6.1.4.1.19376.1.3.10.4.4 Containment Assessment Scales Observation for Scoring Systems APSR2 (2.0) 2016‑10‑06 13:12:00 1.3.6.1.4.1.19376.1.3.10.4.3 ICD-O-3 Typing and Grading Observation (2.0) 2015‑11‑29 17:03:18 Uses as Name Version 1.3.6.1.4.1.19376.1.3.10.9.1 Include X Specimen Identified 2014‑12‑22 15:54:30 1.3.6.1.4.1.19376.1.3.10.9.43 Containment Assessment Scoring Item APSR 2.0 (2.0) 2016‑10‑11 10:26:17 2.16.840.1.113883.10.12.324 Containment CDA Reference 2005‑09‑07 2.16.840.1.113883.10.12.329 Containment CDA Precondition 2005‑09‑07
Relationship	Specialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 (2014‑05‑14 17:09:54)
Example	generated example for use case #1, ER-Allred Score <observation negationInd="false" classCode="OBS" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.3.10.9.42"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="278061009 | Scores (qualifier value) |" codeSystem="2.16.840.1.113883.6.96" displayName="Score"/>  <derivationExpr text="sum"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>     <low value="20170224134516"/>  </effectiveTime>  <value code="445104009" codeSystem="2.16.840.1.113883.6.96" displayName="Sum of proportion of positive staining neoplastic cells score and average intensity of staining score for hormone receptors using immunohistochemistry (observable entity)"/>  <methodCode code="0107" displayName="Microscopy" codeSystem="2.16.840.1.113883.5.84"/>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 1..* R -->   <entryRelationship>     <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.43 'Assessment Scoring Item APSR 2.0' (2016-10-11T10:26:17) -->   </entryRelationship>  <reference>     <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->   </reference>  <precondition>     <!-- template 2.16.840.1.113883.10.12.329 'CDA Precondition' (2005-09-07T00:00:00) -->   </precondition>  <referenceRange typeCode="REFV">     <observationRange classCode="OBS" moodCode="EVN.CRT">       <code code="--code--" codeSystem="2.16.840.1.113883.5.4"/>      <text/>      <value xsi:type="ANY"/>      <interpretationCode code="EXP" displayName="Expected" codeSystem="2.16.840.1.113883.5.83"/>    </observationRange>  </referenceRange></observation>
Item DT Card Conf Description Label hl7:observation 0 … 1 R (Ass...2.0) @classCode cs 1 … 1 F OBS @moodCode cs 1 … 1 F EVN @negationInd bl 0 … 1   hl7:templateId II 1 … 1 M (Ass...2.0) @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.10.9.42 hl7:id II 0 … * R (Ass...2.0) hl7:code CV (extensible) 1 … 1 M (Ass...2.0) @code CONF 1 … 1   @code shall be out of choice: 246262008 Score (attribute) @codeSystem 1 … 1 F 2.16.840.1.113883.6.96 (SNOMED Clinical Terms) @codeSystemName 1 … 1 F SCT @displayName 1 … 1 F Score hl7:derivationExpr ST 0 … 1 R This optional field can be used to specify how the total score is calculated. In most cases the total score will be the sum of its components. But complex mathematical functions and/or logical operations are possible as well. (Ass...2.0) hl7:text ED 0 … 1 R Scoring system used (Ass...2.0) hl7:statusCode CS (required) 1 … 1 M (Ass...2.0)   Constraint The observation statusCode is “ completed ” if the observation was actually performed and has produced a result in the  value  element. In other cases the status of the intended observation is “ aborted ” and the result will never come.   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (2014‑03‑26) hl7:effectiveTime IVL_TS 0 … 1 R (Ass...2.0) hl7:value CE (extensible) 1 … * R (Ass...2.0)   CONF @code shall be "any codes from 395531003 | Tumor observable (observable entity) |" @codeSystem shall be "2.16.840.1.113883.6.96" @codeSystemName shall be "SCT" @displayName shall be "any score systems from Tumor observables" or @code shall be "any codes from 273249006 | Assessment scales" @codeSystem shall be "2.16.840.1.113883.6.96" @codeSystemName shall be "SCT" @displayName shall be "any score systems from Assessment scales" hl7:methodCode CE 0 … * R (Ass...2.0)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (2014‑03‑26) Included 1 … * R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30) hl7:specimen 1 … * R Required in XD-LAB when more than one specimen is documented at this level. Always required in APSR. PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified @typeCode cs 0 … 1 F SPC hl7:specimenRole 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified @classCode cs 0 … 1 F SPEC hl7:id II 1 … 1 R Specimen ID, coming from the LIS PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified hl7:entryRelationship 0 … * R Contains 1.3.6.1.4.1.19376.1.3.10.9.43 Assessment Scoring Item APSR 2.0 (2016‑10‑11 10:26:17) (Ass...2.0) where [@typeCode='COMP'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.43']]] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true @inversionInd bl 0 … 1   @negationInd bl 0 … 1   hl7:sequenceNumber INT 0 … 1 (Ass...2.0) hl7:seperatableInd BL 0 … 1 (Ass...2.0) hl7:reference 0 … * R Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07) (Ass...2.0) hl7:precondition 0 … * R Contains 2.16.840.1.113883.10.12.329 CDA Precondition (2005‑09‑07) (Ass...2.0) hl7:referenceRange 0 … * R (Ass...2.0) @typeCode cs 1 … 1 F REFV hl7:observationRange 1 … 1 R (Ass...2.0) @classCode cs 0 … 1 F OBS @moodCode cs 0 … 1 F EVN.CRT hl7:code CD 0 … 1 R (Ass...2.0) @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.4 (Act Code) hl7:text ED 0 … 1 R (Ass...2.0) hl7:value ANY 0 … 1 R (Ass...2.0) hl7:interpretationCode CE 0 … 1 R (Ass...2.0)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)

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• 2016-10-10 11:33:36 (Under develeopment)