Item | DT | Card | Conf | Description | Label |
---|
| | 1 … 1 | M | | PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section |
| @classCode
|
| cs | 0 … 1 | F | DOCSECT |
| @moodCode
|
| cs | 0 … 1 | F | EVN |
| Constraint | This section SHALL contain a code element populated with these attributes: @code="46059-2" @codeSystem="2.16.840.1.113883.6.1" @displayName="Special treatments and procedures section" This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader. This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document. This section SHALL contain a Specimen Procedure Steps entry element. |
| | Associated with concepts:psr-dataelement-23 | Procedure | APSR 2.0 |
|
| hl7:templateId
|
| II | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section |
| | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.8.1.2.6 |
| hl7:code
|
| CE | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section |
| | @code
|
| CONF | 1 … 1 | F | 46059-2 |
| | @codeSystem
|
| 1 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) |
| | @displayName
|
| 1 … 1 | F | Special treatments and procedures section |
| | @codeSystemName
|
| 1 … 1 | F | LOINC |
| hl7:title
|
| ST | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section |
| CONF | element content shall be "PROCEDURE STEPS" |
|
| hl7:text
|
| SD.TEXT | 1 … 1 | M | | PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section |
| Example | <text>Part #1 is labeled “left breast biopsy” and has been sampled for frozen section preparation. Numerous sections are submitted for permanent processing. Part #2 received in two pieces is labeled "apical left axillary tissue". Both pieces are rendered into numerous sections and submitted in their entirety for history. </text> |
Included | 0 … * | C | from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author (DYNAMIC) Author
Source: PaLM Suppl.APSR 2.0‑3:6.3.6.2
|
| hl7:author
|
| | 0 … * | C | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | @typeCode
|
| cs | 0 … 1 | F | AUT |
| | @contextControlCode
|
| cs | 0 … 1 | F | OP |
| | Associated with concepts:psr-dataelement-4 | Pathologist | APSR 2.0 | psr-dataelement-79 | Device | APSR 2.0 |
|
| Example | author is a person <author typeCode="AUT" contextControlCode="OP"> <time value="201306101654"/> <assignedAuthor classCode="ASSIGNED"> <!-- ... --> </assignedAuthor></author> |
| | hl7:functionCode
|
| CE | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| CONF | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC) |
|
| | hl7:time
|
| TS.DATE.MIN | 1 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | hl7:assignedAuthor
|
| | 1 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| cs | 0 … 1 | F | ASSIGNED |
| II | 1 … * | | | 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 |
| TEL | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
Choice | 1 … 1 | | Elements to choose from:- hl7:assignedPerson
- hl7:assignedAuthoringDevice
|
| | … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
Included | 0 … * | | from 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC) |
| | 0 … 1 | F | PSN |
| | 0 … 1 | F | INSTANCE |
| PN | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | | | hl7:assignedAuthoringDevice
|
| | … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| cs | 0 … 1 | F | DEV |
| cs | 0 … 1 | F | INSTANCE |
| | | | | hl7:manufacturerModelName
|
| SC | 1 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| SC | 1 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | | hl7:representedOrganization
|
| | 1 … 1 | M | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| Example | author is a device <representedOrganization classCode="ORG" determinerCode="INSTANCE"> <name> <!-- ... --> </name></representedOrganization> |
Included | | | from 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC) |
| | 0 … 1 | F | ORG |
| | 0 … 1 | F | INSTANCE |
| II | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| ON | 1 … 1 | | | 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 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| hl7:entry
|
| | 0 … * | | Specimen procedure steps
Source: PaLM Suppl.APSR 2.0‑3:6.2.5.3 Contains 1.3.6.1.4.1.19376.1.3.10.4.1 Specimen Procedure Step (DYNAMIC) | PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | | |