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Version vom 25. Februar 2017, 03:44 Uhr

Id1.3.6.1.4.1.19376.1.3.10.4.1Effective Date valid from 2016‑07‑08 13:20:59

There are versions of templates with this id:
  • SpecimenProcedureStep as of 2016‑07‑08 13:20:59
  • SpecimenProcedureStep as of 2014‑07‑29 16:02:02
StatusKyellow.png DraftVersion Label2.0
NameSpecimenProcedureStepDisplay NameSpecimen Procedure Step
DescriptionTemplate CDA Procedure (prototype, directly derived from POCD_RM000040 MIF)
for Specimen procedure step in APSR2.

This entry collects all the information of source, method and result of a specimen procedure from the collection out of the patient through the final product of a stained histologic section or cytologic smear on a glass slide, or a WSI of such a slide. It reflects the workflow and the probe tracking of a pathology laboratory.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.1
LabelPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
ClassificationCDA Entry Level Template
Open/ClosedClosed (only defined elements are allowed)
Associated with
Associated with 6 concepts
IdNameData Set
psr-data​element-24Specimen collectionAPSR 2.0
psr-data​element-25Specimen processingAPSR 2.0
psr-data​element-87Procedure IDAPSR 2.0
psr-data​element-89Procedure StepAPSR 2.0
psr-data​element-90Requested ProcedureAPSR 2.0
psr-data​element-94Target SiteAPSR 2.0
Used by / Uses
Used by 4 templates, Uses 7 templates
Used by Template id as NameVersion
1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKvalidblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
1.3.6.1.4.1.19376.1.8.1.2.6Link.pngKyellow.png Procedure Steps Section (2.0)2014‑05‑13 19:33:12
1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses Template id as NameVersion
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen IdentifiedDYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2008)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA authorDYNAMIC
1.3.6.1.4.1.19376.1.3.10.9.20ContainmentKyellow.png CDA Participant (Body) Procedure Steps APSR2 (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.3.10.9.22ContainmentKyellow.png CDA Supply Container APSR2 (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.3.1.3ContainmentKyellow.png Specimen Received (2016)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.306 (2005‑09‑07)
Specialization: template 1.3.6.1.4.1.19376.1.3.1.2 (2016‑07‑05)
Example
generated example
<procedure negationInd="false" classCode="PROC" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.4.1"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="117617002" displayName="Immunohistochemistry procedure (procedure)" codeSystem="2.16.840.1.113883.5.96">
    <qualifier>
      <name code="246094008 or 246355002" codeSystem="2.16.840.1.113883.6.96" displayName="Component investigated (attribute) or Supporting structure (attribute)"/>      <value nullFlavor="cs" code="23307004" codeSystem="2.16.840.1.113883.6.96" displayName="Estrogen receptor (substance)"/>    </qualifier>  </code>  <text/>  <statusCode code="normal"/>  <effectiveTime>
    <low value="20161110104817"/>  </effectiveTime>  <targetSiteCode code="441652008" codeSystem="2.16.840.1.113883.6.96" displayName="Formalin-fixed paraffin-embedded tissue specimen (specimen)"/>  <specimen typeCode="SPC">
    <specimenRole classCode="SPEC">
      <id/>    </specimenRole>  </specimen>  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'CDA Performer IHE (Body)' (dynamic) -->
  </performer>  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) -->
  </author>  <participant>
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.20 'CDA Participant (Body) Procedure Steps APSR2' (dynamic) -->
  </participant>  <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">
    <seperatableInd value="false"/>    <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.22 'CDA Supply Container APSR2' (dynamic) -->
  </entryRelationship>  <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">
    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.3.1.3 'Specimen Received' (dynamic) -->
  </entryRelationship>  <entryRelationship negationInd="false" typeCode="REFR" inversionInd="false" contextConductionInd="true">
    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.4.1 'Specimen Procedure Step' (dynamic) -->
  </entryRelationship></procedure>
ItemDTCardConfDescriptionLabel
hl7:procedure
1 … *RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treetree.png@classCode
cs1 … 1FPROC
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
 Target.pngAssociated with concepts:
psr-data​element-24Specimen collectionAPSR 2.0
psr-data​element-25Specimen processingAPSR 2.0
psr-data​element-90Requested ProcedureAPSR 2.0
Treetree.pnghl7:templateId
II1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.4.1
Treetree.pnghl7:id
II1 … 1MProcedure ID, coming from the LIS.
May be the target (referenced) ID for the child procedure.		PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 Target.pngAssociated with concepts:
psr-data​element-87Procedure IDAPSR 2.0
psr-data​element-89Procedure StepAPSR 2.0
Treetree.pnghl7:code
CD CWE1 … 1MCoded procedurePaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 Constraint
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.10 Specimen Collection and Processing (DYNAMIC)
Treeblank.pngTreetree.pnghl7:qualifier
CR0 … *CQualifier for staining or other procedures which don´t have values in the vocabulary used.
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 ConstraintUsed only in staining and other procedures without values in SCT or LOINC or DICOM vocabulary, e.g. immune stains
 Example
Estrogen receptor
<qualifier>
  <name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/>  <value code="23307004" displayName="Estrogen receptor (substance)" codeSystem="2.16.840.1.113883.6.96"/></qualifier>
 Example
ISH Her-2-neu
<qualifier>
  <name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/>  <value code="164870" displayName="ONCOGENE ERBB2" codeSystem="2.16.840.1.113883.6.174" codeSystemName="OMIM"/></qualifier>
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1F246094008 or 246355002
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
cs1 … 1F2.16.840.1.113883.6.96
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
cs0 … 1FComponent investigated (attribute) or Supporting structure (attribute)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD CWE1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs1 … 1R
 CONF
@code shall be "<<105590001 | Substance (substance) |"
@codeSystem shall be "2.16.840.1.113883.6.96"
@displayName shall be "values from substance axis, e.g. Estrogen receptor"
@codeSystemName shall be "SNOMED-CT"
or
@code shall be "values from G axis"
@codeSystem shall be "2.16.840.1.113883.6.174"
@displayName shall be "values from G axis, e.g. erb-b2"
@codeSystemName shall be "OMIM"
or
@code shall be "<<272394005 | Technique (qualifier value) |"
@codeSystem shall be "2.16.840.1.113883.6.96"
@displayName shall be "values from technique axis, e.g. Paraffin embedded (qualifier)"
@codeSystemName shall be "SNOMED-CT"
Treetree.pnghl7:text
ED0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 Example
specimen collection procedure
<text>ULTRASOUND GUIDED NEEDLE CORE BIOPSY</text>
 Example
specimen processing procedure
<text>CUTTING A SLIDE FROM A PARAFFIN BLOCK</text>
Treetree.pnghl7:statusCode
CS CNE1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treetree.pnghl7:target​Site​Code
CD CWE0 … *Rtarget site in body or relative parent relationship in case of  specimen processingPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 CONF
@codeSystem shall be "2.16.840.1.113883.5.1052"
or
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.9 Procedure Site (DYNAMIC)
or
@code shall be "<<123037004 | Body structure (body structure) |"
@codeSystem shall be "2.16.840.1.113883.6.96"
@displayName shall be "all children of Body structure (body structure)"
@codeSystemName shall be "SCT"
 Target.pngAssociated with concepts:
psr-data​element-94Target SiteAPSR 2.0
Treeblank.pngTreetree.pnghl7:qualifier
CR0 … *optional qualifiers for specifying body structures or / and lateralityPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 Example
Specification of body structure for specimen collection
<qualifier>
  <name code="118169006" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen source topography (attribute)" codeSystemName="SNOMED-CT"/>  <value code="255495000" codeSystem="2.16.840.1.113883.6.96" displayName="Right lower quadrant (qualifier value)" codeSystemName="SNOMED-CT"/></qualifier>
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st0 … 1FSpecimen source topography
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F2.16.840.1.113883.6.96
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1F118169006
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD CWE0 … *RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF1 … 1 @code shall be out of choice:
  • <<272099008
  • Descriptor (qualifier value)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.96 (SNOMED Clinical Terms)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
1 … 1Fall children of "Descriptor, qualifier values", e.g. right lower quadrantt
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
1 … 1FSCT
Treetree.pnghl7:methodCode
CD0 … *Identifies the technique used to perform a procedure
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreetree.png@codeSystem
cs1 … 1F2.16.840.1.113883.5.1065
Included0 … * from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC)
Parent specimen with parent ID
Treetree.pnghl7:specimen
0 … *RRequired 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
 Target.pngAssociated with concepts:
psr-data​element-17Specimen identificationAPSR 2.0
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
 Target.pngAssociated with concepts:
psr-data​element-68Tissue section IDAPSR 2.0
psr-data​element-98Specimen IDAPSR 2.0
psr-data​element-66Part IDAPSR 2.0
psr-data​element-67Block IDAPSR 2.0
psr-data​element-95Parent IDAPSR 2.0
Treetree.pnghl7:performer
0 … *Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC)PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treetree.pnghl7:author
0 … *Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author (DYNAMIC)PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treetree.pnghl7:participant
1 … *MOne or more specimen (with additives), which participates as product of the procedure
Contains 1.3.6.1.4.1.19376.1.3.10.9.20 CDA Participant (Body) Procedure Steps APSR2 (DYNAMIC)		PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.png where [not(@nullFlavor)]
Treetree.pnghl7:entryRelationship
0 … *RArtificial material (manufactured product) which containes the specimen
Contains 1.3.6.1.4.1.19376.1.3.10.9.22 CDA Supply Container APSR2 (DYNAMIC)		PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treeblank.pngTreetree.png@inversionInd
bl0 … 1 
Treeblank.pngTreetree.png@negationInd
bl0 … 1 
 Constraintfor manufactured product
classCode = MANU

for DrugOrOtherMaterial
classCode = MMAT
code from MaterialEntityClassType
Treeblank.pngTreetree.pnghl7:seperatableInd
BL0 … *PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treetree.pnghl7:entryRelationship
0 … 1RSpecimen arrival in Lab
Contains 1.3.6.1.4.1.19376.1.3.1.3 Specimen Received (DYNAMIC)		PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treeblank.pngTreetree.png@inversionInd
bl0 … 1 
Treeblank.pngTreetree.png@negationInd
bl0 … 1 
 Constraint
Treeblank.pngTreetree.pnghl7:seperatableInd
BL0 … *PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … *PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treetree.pnghl7:entryRelationship
0 … 4RReferencing mechanism to the ID of the parent procedure
Contains 1.3.6.1.4.1.19376.1.3.10.4.1 Specimen Procedure Step (DYNAMIC)		PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFR
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treeblank.pngTreetree.png@inversionInd
bl0 … 1 
Treeblank.pngTreetree.png@negationInd
bl0 … 1 
 Constraintcontains only ID of the child procedure, which is fully described in a dedicated entry further down in the Procedure step section.
Treeblank.pngTreetree.pnghl7:seperatableInd
BL0 … *PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
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