| Item | DT | Card | Conf | Description | Label |
|---|
| | 1 … 1 | M | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
 | @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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
 | | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.8.1.1.1 |
| hl7:realmCode
|
| CS (extensible) | 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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| 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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | @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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | @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 (required) | 1 … 1 | M | ClinicalDocument/code SHALL be present. The document type of this content module is always
<code code="60568-3"
codeSystem="2.16.840.1.113883.6.1"
displayName="Pathology Synoptic report"
codeSystemName="LOINC"/>
| PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | @code
|
| CONF | 1 … 1 | F | 60568-3 |
| | @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 Synoptic report |
| hl7:title
|
| ST | 1 … 1 | M | The APSR <title> SHALL be present. It is the local translation of the code@displayName.
| PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | 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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| hl7:confidentialityCode
|
| CE (required) | 1 … 1 | M | ClinicalDocument/confidentialityCode SHALL be present in accordance with the HL7 CDA R2 standard.
| PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (2014‑06‑09) |
|
| hl7:languageCode
|
| CS (required) | 1 … 1 | M | ClinicalDocument/languageCode SHALL be present in accordance with the HL7 CDA R2 standard.
| PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (2014‑03‑26) |
|
| 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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | @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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | @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 (2017‑06‑07)
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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | hl7:patientRole
|
| | 1 … 1 | R | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| II | 1 … * | R | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| AD | 1 … * | | All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| TEL | 1 … * | | All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | 1 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| II | 0 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| PN | 1 … * | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | | | hl7:administrativeGenderCode
|
| CE | 1 … 1 | R | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| TS | 1 … 1 | R | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| Included | 1 … * | M | from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
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 |
| 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 |
| cs | 0 … 1 | F | ASSIGNED |
| II | 1 … * | M | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| AD | 1 … * | M | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| 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:assignedPerson
- hl7:assignedAuthoringDevice
|
| | 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 (2005‑09‑07)
The name(s) SHALL be given. |
| | 0 … 1 | F | PSN |
| | 0 … 1 | F | INSTANCE |
| PN | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | | | hl7:assignedAuthoringDevice
|
| | 0 … 1 | C | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| cs | 0 … 1 | F | DEV |
| cs | 0 … 1 | F | INSTANCE |
| | | | | hl7:manufacturerModelName
|
| SC | 0 … 1 | R | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| SC | 0 … 1 | R | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| CE | 0 … 1 | R | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | | hl7:representedOrganization
|
| | 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 (2005‑09‑07)
The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given. |
| | 0 … 1 | F | ORG |
| | 0 … 1 | F | INSTANCE |
| II | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| ON | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| TEL | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| 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 |
| | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | 0 … 1 | F | PART |
| II | 0 … * | R | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| CE | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| CONF | 0 … 1 | F | 2.16.840.1.113883.5.111 (Role Code) |
| 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) |
|
| IVL_TS | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | 0 … 1 | F | ORG |
| | 0 … 1 | F | INSTANCE |
| II | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| ON | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| TEL | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| 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 (2005‑09‑07)
Transcriptionist
|
| hl7:dataEnterer
|
| | 0 … * | R | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | @typeCode
|
| | 0 … 1 | F | ENT |
| | @contextControlCode
|
| | 0 … 1 | F | OP |
| | hl7:time
|
| TS | 0 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | hl7:assignedEntity
|
| | 1 … 1 | | Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| 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 (2016‑07‑08 11:22:58) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.6']] |
| |
| Included | 1 … 1 | M | from 2.16.840.1.113883.10.12.104 CDA custodian (2005‑09‑07)
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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | @typeCode
|
| | 0 … 1 | F | CST |
| | hl7:assignedCustodian
|
| | 1 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | 0 … 1 | F | ASSIGNED |
| | | hl7:representedCustodianOrganization
|
| | 1 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | 0 … 1 | F | ORG |
| | 0 … 1 | F | INSTANCE |
| II | 1 … * | M | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| ON | 0 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| TEL | 0 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| AD | 0 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| Included | 0 … * | R | from 1.3.6.1.4.1.19376.1.3.3.1.4 XD-LAB Information Recipient (2008‑08‑08)
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:informationRecipient
|
| | 0 … * | R | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | hl7:templateId
|
| II | 1 … 1 | M | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.3.3.1.4 |
| | hl7:intendedRecipient
|
| | 1 … 1 | R | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| II | 0 … * | R | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| AD | 1 … * | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| TEL | 1 … * | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | | hl7:informationRecipient
|
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.3.10.9.18 PlayingEntity or person with Name (DYNAMIC) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | | hl7:receivedOrganization
|
| | 0 … 1 | | Contains 1.3.6.1.4.1.19376.1.3.10.9.13 Organization with Name, Addr, Telecom (DYNAMIC) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| Included | 1 … 1 | M | from 1.3.6.1.4.1.19376.1.3.10.2.4 XD-LAB LegalAuthenticator (2016‑07‑05)
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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | hl7:time
|
| TS | 1 … 1 | R | The sub-element time carries the date&time this legal authentication took place. | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | hl7:signatureCode
|
| CS | 1 … 1 | R | The sub-element signatureCode carries the “signed” (S) status | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| CONF | 0 … 1 | F | S |
| | hl7:assignedEntity
|
| | 1 … 1 | R | All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| AD | 1 … * | R | Constrained by this specification to require the presence of name, addr and telecom. | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| TEL | 1 … * | R | Constrained by this specification to require the presence of name, addr and telecom. | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | 0 … 1 | | All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.
Contains 1.3.6.1.4.1.19376.1.3.10.9.18 PlayingEntity or person with Name (DYNAMIC) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | | hl7:representedOrganization
|
| | 0 … 1 | | All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.
Contains 1.3.6.1.4.1.19376.1.3.10.9.13 Organization with Name, Addr, Telecom (DYNAMIC) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| Included | 0 … * | R | from 1.3.6.1.4.1.19376.1.8.1.4.3 CDA authenticator IHE (2016‑07‑09 15:03:59)
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 |
| 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 (2005‑09‑07) | 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 (2008‑08‑08)
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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | @typeCode
|
| cs | 1 … 1 | F | REF |
| | hl7:templateId
|
| II | 1 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| 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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | hl7:associatedEntity
|
| | 1 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| AD | 1 … * | R | The address of this person (referral ordering physician) SHALL be present. | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| TEL.AT | 1 … * | R | The telecom of this person (referral ordering physician) SHALL be present. | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | Schematron assert | role |  error | |
| | test | not(hl7:assignedPerson) or hl7:assignedPerson/hl7:name | |
| | Message | The <name> sub-element SHALL be present when <assignedPerson> present. | |
| | 0 … 1 | R | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | 0 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| Included | 0 … * | R | from 1.3.6.1.4.1.19376.1.8.1.4.1 CDA Participant Specimen Collector (2016‑06‑13 14:21:13)
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 |
| 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:associatedEntity
|
| | 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 |
| cs | 1 … 1 | F | PROV |
| II | 1 … * | R | | PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector |
| AD | 1 … * | R | | PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector |
| TEL.AT | 1 … * | R | | PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector |
| | 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 (2005‑09‑07) | PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector |
| | 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 (2005‑09‑07) | PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector |
| Included | 0 … 1 | R | from 1.3.6.1.4.1.19376.1.3.10.2.5 CDA Participant Pertinent Insurance Information (2017‑11‑13 16:52:30)
Key insurance information of the patient |
| hl7:participant
|
| | 0 … 1 | R | Insurance information of the patient in context for reporting to cancer registries (in Germany) | PaLM Suppl. 2.0‑3:6.3.6.13 |
| | @typeCode
|
| cs | 1 … 1 | F | HLD |
| | hl7:templateId
|
| II | 1 … * | M | | PaLM Suppl. 2.0‑3:6.3.6.13 |
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.3.10.2.5 |
| | hl7:time
|
| IVL_TS | 0 … 1 | R | time shows the end of the current insurance period, e.g. end of the quartal | PaLM Suppl. 2.0‑3:6.3.6.13 |
| | Example | <time>
<high value="20171231"/></time> |
| | hl7:associatedEntity
|
| | 1 … 1 | M | Data of the insured person | PaLM Suppl. 2.0‑3:6.3.6.13 |
| cs | 1 … 1 | F | POLHOLD |
| II | 0 … * | R | ID(s) of the insured person (patient), e.g. ID of the insured, ID of the health card, etc. | PaLM Suppl. 2.0‑3:6.3.6.13 |
| CE | 0 … 1 | R | status of the insured person | PaLM Suppl. 2.0‑3:6.3.6.13 |
| CONF | 0 … 1 | F | 2.16.840.1.113883.5.111 (Role Code) |
| | Example | <code code="SELF" codeSystem="2.16.840.1.113883.5.111" displayName="self">
<translation code="1" codeSystem="2.16.840.1.113883.3.7.1.1" displayName="member"/></code> |
| CV | 0 … 1 | R | further codes of the status of the insured person,
e.g. for Germany from value set S_KBV_VERSICHERTENSTATUS
1.2.276.0.76.11.162 | PaLM Suppl. 2.0‑3:6.3.6.13 |
| AD | 0 … 1 | R | | PaLM Suppl. 2.0‑3:6.3.6.13 |
| TEL | 0 … * | R | | PaLM Suppl. 2.0‑3:6.3.6.13 |
| | 0 … 1 | R | Data of the insured person, which may be different from the patient.
Contains 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07) | PaLM Suppl. 2.0‑3:6.3.6.13 |
| | 1 … 1 | R | Data of the Insurance company, including the ID, the address data and the name.
In Germany the ID is formed by the ID itself (@extension = so-called IKNR) and the OID for IKNR (@root="1.2.276.0.76.4.5") in Germany.
Contains 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07) | PaLM Suppl. 2.0‑3:6.3.6.13 |
| 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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | @typeCode
|
| cs | 1 … 1 | F | FLFS |
| | hl7:order
|
| | 1 … 1 | M | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| cs | 1 … 1 | F | ACT |
| cs | 1 … 1 | F | RQO |
| II | 1 … * | R | Placer order group ID or Placer order ID
| PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| hl7:documentationOf
|
| | 1 … 1 | M | Documented act. | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | @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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| cs | 1 … 1 | R | |
| cs | 1 … 1 | R | |
| II | 1 … * | M | ID of the Act, i.e. Accession number | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| CE (extensible) | 0 … 1 | R | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | 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)" |
|
| 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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| CS (required) | 0 … 1 | R |
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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | 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 (2008‑08‑08) |
|
| | Schematron assert | role | error | |
| | test | hl7:serviceEvent/lab:statusCode[@code='completed'] | |
| | Message | Status code of all Content Modules SHALL be "complete" or "aborted" | |
| | 0 … * | R | Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | | where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.3.1.7']] |
| |
| 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 AP structured 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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | @typeCode
|
| cs | 1 … 1 | F | RPLC |
| | relatedDocument@typeCode attribute SHALL be valued "RPLC"
|
| | hl7:parentDocument
|
| ANY | 1 … 1 | M | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| II | 1 … 1 | M | SHALL be equal to ClinicalDocument/ id of the replaced document.
| PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| II | 1 … 1 | M | SHALL have the same value in the new report as in the replaced report.
| PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| INT | 0 … 1 | R | SHALL have the same value as in the replaced report (when provided there).
| PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| Included | 0 … 1 | R | from 2.16.840.1.113883.10.12.113 CDA componentOf (2005‑09‑07)
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 Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | @typeCode
|
| | 0 … 1 | F | COMP |
| | hl7:encompassingEncounter
|
| | 1 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | 0 … 1 | F | ENC |
| | 0 … 1 | F | EVN |
| II | 0 … * | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| CE | 0 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC) |
|
| IVL_TS | 1 … 1 | R | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | | hl7:dischargeDispositionCode
|
| CE | 0 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | CONF | | shall be drawn from concept domain "EncounterDischargeDisposition" |
|
| | 0 … 1 | | Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | 0 … 1 | F | RESP |
| | 0 … * | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| 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) |
|
| IVL_TS | 0 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | 1 … 1 | | Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | 0 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | 0 … 1 | F | LOC |
| | 1 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | 0 … 1 | F | SDLOC |
| II | 0 … * | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| CE | 0 … 1 | | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC) |
|
| | 0 … 1 | | Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | | | | hl7:serviceProviderOrganization
|
| | 0 … 1 | | Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| hl7:component
|
| | 1 … 1 | R | Body of the CDA Clinical document | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 1 … 1 | F | true |
| | hl7:structuredBody
|
| | 1 … 1 | R | | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| cs | 1 … 1 | F | DOCBODY |
| cs | 1 … 1 | F | EVN |
| | 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 (2014‑05‑13 14:38:08) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | | where [@typeCode='COMP'] [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.2.1']]] |
| |
| cs | 1 … 1 | F | COMP |
| bl | 1 … 1 | F | true |
| | 0 … 1 | R |
Contains 1.3.6.1.4.1.19376.1.8.1.2.2 Intraoperative Observation Section (2014‑05‑13 19:29:16) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | | where [@typeCode='COMP'] [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.2.2']]] |
| |
| cs | 1 … 1 | F | COMP |
| bl | 1 … 1 | F | true |
| | 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 (2014‑05‑13 11:57:09) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | | where [@typeCode='COMP'] [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.2.3']]] |
| |
| cs | 1 … 1 | F | COMP |
| bl | 1 … 1 | F | true |
| | 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 (2014‑05‑13 14:25:17) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | | where [@typeCode='COMP'] [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.2.4']]] |
| |
| cs | 1 … 1 | F | COMP |
| bl | 1 … 1 | F | true |
| | 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 (2016‑11‑13 14:28:08) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | | where [@typeCode='COMP'] [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.3.1']]] |
| |
| cs | 1 … 1 | F | COMP |
| bl | 1 … 1 | F | true |
| | 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 (2014‑05‑13 19:31:26) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | | where [@typeCode='COMP'] [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.2.5']]] |
| |
| cs | 1 … 1 | F | COMP |
| bl | 1 … 1 | F | true |
| | 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 (2014‑05‑13 19:33:12) | PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module |
| | | where [@typeCode='COMP'] [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.2.6']]] |
| |
| cs | 1 … 1 | F | COMP |
| bl | 1 … 1 | F | true |
Draft
