1.3.6.1.4.1.19376.1.3.10.4.4/static-2016-10-06T131200

Id	1.3.6.1.4.1.19376.1.3.10.4.4	Effective Date	valid from 2016‑10‑06 13:12:00 There are versions of templates with this id: AssessmentScalesObservationScoringSystemsAPSR as of 2016‑10‑06 13:12:00 AssessmentScalesScoringSystemsAPSR as of 2016‑10‑06 12:36:29 CDASupplyContainerAPSR2 as of 2016‑07‑29
Status	Draft	Version Label	2.0
Name	AssessmentScalesObservationScoringSystemsAPSR	Display Name	Assessment Scales Observation for Scoring Systems APSR2
Description	Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF) Assessment scale observation for Scoring Systems, e.g. Nottingham- (Elston-Ellis-) Grading for invasive breast cancers, describing the summarized scale value
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.4
Label	PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Classification	CDA Entry Level Template
Open/Closed	Closed (only defined elements are allowed)
Associated with	Associated with 1 concept Id Name Data Set psr-data​element-99 Assessment Scales APSR 2.0
Used by / Uses	Used by 9 templates, Uses 3 templates Used by Template id as Name Version 1.3.6.1.4.1.19376.1.3.10.4.3 Containment ICD-O-3 Typing and Grading Observation (2.0) 2015‑11‑29 17:03:18 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (2.0) 2015‑08‑13 10:24:55 1.3.6.1.4.1.19376.1.3.10.3.1 Additional Specified Observation Section (2.0) 2016‑11‑13 14:28:08 1.3.6.1.4.1.19376.1.8.1.1.1 Anatomic Pathology Structured Report Content Module (2.0) 2014‑05‑13 11:57:57 1.3.6.1.4.1.19376.1.8.1.2.1 Clinical Information Section (2.0) 2014‑05‑13 14:38:08 1.3.6.1.4.1.19376.1.8.1.2.2 Intraoperative Observation Section (2.0) 2014‑05‑13 19:29:16 1.3.6.1.4.1.19376.1.8.1.2.3 Macroscopic Observation Section (2.0) 2014‑05‑13 11:57:09 1.3.6.1.4.1.19376.1.8.1.2.4 Microscopic Observation Section (2.0) 2014‑05‑13 14:25:17 1.3.6.1.4.1.19376.1.8.1.2.5 Diagnostic Conclusion Section (2.0) 2014‑05‑13 19:31:26 Uses Template id as Name Version 1.3.6.1.4.1.19376.1.3.10.9.1 Include X Specimen Identified DYNAMIC 1.3.6.1.4.1.19376.1.3.10.9.42 Containment Assessment Scoring System APSR 2.0 (2.0) DYNAMIC 2.16.840.1.113883.10.12.324 Containment CDA Reference DYNAMIC
Relationship	Specialization: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Example	Example <observation negationInd="false" classCode="OBS" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.3.10.4.4"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="273249006" codeSystem="2.16.840.1.113883.6.96" displayName="Assessment scales"/>  <derivationExpr/>  <text/>  <statusCode code="normal"/>  <effectiveTime>     <low value="20170131163655"/>  </effectiveTime>  <priorityCode code="A" displayName="ASAP" codeSystem="2.16.840.1.113883.5.7"/>  <repeatNumber/>  <languageCode code="aa"/>  <value xsi:type="INT" value="1"/>  <interpretationCode code="CAR" displayName="Carrier" codeSystem="2.16.840.1.113883.5.83"/>  <methodCode code="0114" codeSystem="2.16.840.1.113883.1.11.14079" displayName="Microscopy, Light"/>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 0..* O -->   <entryRelationship typeCode="SPRT">     <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.42 'Assessment Scoring System APSR 2.0' (dynamic) -->   </entryRelationship>  <reference>     <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (dynamic) -->   </reference>  <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="CAR" displayName="Carrier" codeSystem="2.16.840.1.113883.5.83"/>    </observationRange>  </referenceRange></observation>
Item DT Card Conf Description Label hl7:observation 0 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales @classCode cs 0 … 1 F OBS @moodCode cs 1 … 1 F EVN @negationInd bl 0 … 1     Associated with concepts: psr-data​element-99 Assessment Scales APSR 2.0 hl7:templateId II 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.10.4.4 hl7:id II 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales hl7:code CE CWE 1 … 1 M Assessment scale, e.g. grading by scoring PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales   CONF @code shall be "273249006" @codeSystem shall be "2.16.840.1.113883.6.96" @displayName shall be "Assessment scales" @codeSystemName shall be "SCT" or The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19918 ActCoverageAssessmentObservationValue (DYNAMIC) hl7:derivationExpr ST 0 … 1 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. PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales hl7:text ED 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales hl7:statusCode CS 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC) hl7:effectiveTime IVL_TS 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales hl7:priorityCode CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC) hl7:repeatNumber IVL_INT 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales hl7:language​Code CS 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC) hl7:value INT 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales   Constraint any value of a scoring systems, e.g. Gleason score, van Nuys score, etc. hl7:interpretationCode CE 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 Observation Interpretation (HL7) (DYNAMIC) hl7:methodCode CE 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales @code CONF 1 … 1 F 0114 @codeSystem 1 … 1 F 2.16.840.1.113883.1.11.14079 @displayName 1 … 1 F Microscopy, Light @codeSystemName 1 … 1 F HL7 Included 0 … * from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC) hl7:specimen 0 … * 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   Associated with concepts: psr-data​element-17 Specimen identification APSR 2.0 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   Associated with concepts: psr-data​element-68 Tissue section ID APSR 2.0 psr-data​element-98 Specimen ID APSR 2.0 psr-data​element-66 Part ID APSR 2.0 psr-data​element-67 Block ID APSR 2.0 psr-data​element-95 Parent ID APSR 2.0 hl7:entryRelationship 0 … * Contains 1.3.6.1.4.1.19376.1.3.10.9.42 Assessment Scoring System APSR 2.0 (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales @typeCode cs 1 … 1 F SPRT hl7:sequenceNumber INT 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales hl7:reference 0 … * Contains 2.16.840.1.113883.10.12.324 CDA Reference (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales hl7:referenceRange 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales @typeCode cs 1 … 1 F REFV hl7:observationRange 1 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales @classCode cs 0 … 1 F OBS @moodCode cs 0 … 1 F EVN.CRT hl7:code CD 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales @codeSystem CONF 1 … 1 F 2.16.840.1.113883.5.4 (Act Code) hl7:text ED 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales hl7:value ANY 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales hl7:interpretationCode CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 Observation Interpretation (HL7) (DYNAMIC)