1.3.6.1.4.1.19376.1.8.1.2.4/static-2014-05-13T142517

Id	1.3.6.1.4.1.19376.1.8.1.2.4	Effective Date	valid from 2014‑05‑13 14:25:17
Status	Draft	Version Label	2.0
Name	MicroscopySection	Display Name	Microscopic Observation Section
Description	The Microscopic Observation section contains optionally the histopathologic findings of the case and of all of the derived specimens. This section should be used to record the results of histochemical and immunohistochemical stains and of image-based molecular methods.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.4
Label	PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
Classification	CDA Section Level Template
Open/Closed	Closed (only defined elements are allowed)
Associated with	Associated with 2 concepts Id Name Data Set psr-data​element-15 Microscopic observation APSR 2.0 psr-data​element-16 microscopic observation text APSR 2.0
Used by / Uses	Used by 1 template, Uses 2 templates Used by Template id as Name Version 1.3.6.1.4.1.19376.1.8.1.1.1 Containment Anatomic Pathology Structured Report Content Module (2.0) 2014‑05‑13 11:57:57 Uses Template id as Name Version 1.3.6.1.4.1.19376.1.8.1.4.2 Include CDA author DYNAMIC 1.3.6.1.4.1.19376.1.8.1.3.6 Containment Problem Organizer (2.0) DYNAMIC
Relationship	Specialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example	Example <section>   <templateId root="1.3.6.1.4.1.19376.1.8.1.2.4"/>  <code code="22635-7" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report microscopic observation"/>  <title>Microscopic observation</title>  <text/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) 0..* C -->   <entry>     <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (dynamic) -->   </entry>  <component typeCode="COMP">     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (dynamic) -->   </component></section>
Item DT Card Conf Description Label hl7:section 0 … 1 R PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section   Constraint This section SHALL contain a code element populated with these attributes: @code="22635-7" @codeSystem="2.16.840.1.113883.6.1" @displayName="Pathology report microscopic observation"  This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader. The section SHOULD contain as many Problem Organizer entry elements as there are problems or groups thereof to be described. These entries provide the machine-readable data corresponding to the narrative block. 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 does not contain any subsections.    Associated with concepts: psr-data​element-15 Microscopic observation APSR 2.0 hl7:templateId II 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.2.4 hl7:code CE 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section @code CONF 1 … 1 F 22635-7 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) @displayName 1 … 1 F Pathology report microscopic observation @codeSystemName 1 … 1 F LOINC hl7:title ST 1 … 1 R PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section   CONF element content shall be "Microscopic observation"   Example <title>MICROSCOPIC OBSERVATION SECTION</title> hl7:text SD.TEXT 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section   Associated with concepts: psr-data​element-16 microscopic observation text APSR 2.0   Example <text> Sections of part #1 confirm frozen section diagnosis of infiltrating duct carcinoma. It is to be noted that the tumor cells show considerable pleomorphism, and mitotic figures are frequent (as many as 4 per high power field). Total size of primary tumor is estimated to be 3cm in greatest dimension. Many foci of calcification are present within the tumor. Part #2 consists of fibrofatty tissue and includes 18 lymph nodes. All lymph nodes are free of disease with the exception of one lymph node, which contains several micrometastases. </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 @context​Control​Code cs 0 … 1 F OP   Associated with concepts: psr-data​element-4 Pathologist APSR 2.0 psr-data​element-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 @classCode cs 0 … 1 F ASSIGNED hl7:id II 1 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Choice 1 … 1 Elements to choose from: hl7:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person  … 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) @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device  … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name SC 1 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:softwareName SC 1 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:represented​Organization 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) @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 1 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:entry 0 … * R Problem organizer entry Source: PaLM Suppl. APSR 2.0-3: 6.2.5.2 Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (DYNAMIC) PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true