| Item | DT | Card | Conf | Description | Label |
|---|
| | 0 … * | R | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
 | @classCode
|
| cs | 1 … 1 | F | PROC |
| @moodCode
|
| cs | 1 … 1 | F | EVN |
| hl7:templateId
|
| II | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
 | | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.3.10.4.1 |
| hl7:id
|
| II | 0 … * | | Procedure 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 |
| hl7:code
|
| CD CWE | 1 … 1 | M | Coded procedure | PaLM 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) |
|
| | Example | for use case #1, specimen collection <code code="122548005" codeSystem="2.16.840.1.113883.6.96" displayName="Biopsy of breast (procedure)" codeSystemName="SNOMED-CT"/> |
| | Example | for use case #1, grossing & embedding <code code="40923002" codeSystem="2.16.840.1.113883.6.96" displayName="Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)"/> |
| | Example | for use case #1, sectioning & immunostaining <code code="117617002" codeSystem="2.16.840.1.113883.6.96" displayName="Immunohistochemistry procedure (procedure)"/> |
| | hl7:qualifier
|
| CR CWE | 0 … * | C | Qualifier 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 |
| | Constraint | Used only in staining and other procedures without values in SCT or LOINC or DICOM vocabulary, e.g. immune stains
|
| | Example | for use case #1, grossing & embedding <qualifier>
<name code="246355002" displayName="Supporting structure (attribute)" codeSystem="2.16.840.1.113883.6.96"/> <value code="702941008" displayName="Paraffin embedding (qualifier value)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/></qualifier> |
| | Example | for use case #1, Estrogen receptor staining <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 | for use case #1, ISH Her-2-neu staining <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> |
| CV CWE | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| cs | 0 … 1 | F | 246094008_or_246355002 |
| oid | 0 … 1 | F | 2.16.840.1.113883.6.96 |
| st | 0 … 1 | F | Component investigated (attribute) or Supporting structure (attribute) |
| CD CWE | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| cs | 1 … 1 | R | |
| | CONF | | @code shall be "<<105590001 | Substance (substance) |" | | @codeSystem shall be "2.16.840.1.113883.6.96" | | @codeSystemName shall be "SNOMED-CT" | | @displayName shall be "values from substance axis, e.g. Estrogen receptor" | | or | | @code shall be "values from G axis" | | @codeSystem shall be "2.16.840.1.113883.6.174" | | @codeSystemName shall be "OMIM" | | @displayName shall be "values from G axis, e.g. erb-b2" | | or | | @code shall be "<<272394005 | Technique (qualifier value) |" | | @codeSystem shall be "2.16.840.1.113883.6.96" | | @codeSystemName shall be "SNOMED-CT" | | @displayName shall be "values from technique axis, e.g. Paraffin embedded (qualifier)" |
|
| hl7:text
|
| ED | 0 … 1 | R | | PaLM 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> |
| hl7:statusCode
|
| CS CNE | 1 … 1 | R | | PaLM 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) |
|
| hl7:effectiveTime
|
| IVL_TS | 0 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| hl7:approachSiteCode
|
| CD CWE | 0 … 1 | | Approach site in specimen collection | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| | @code
|
| CONF | 1 … 1 | F | any_code |
| | @codeSystem
|
| 1 … 1 | F | 2.16.840.1.113883.5.1052 (Act Site) |
| | @codeSystemName
|
| 1 … 1 | F | any_code |
| | @displayName
|
| 1 … 1 | F | ActSite |
| hl7:targetSiteCode
|
| CD CWE | 0 … 1 | R | Target site in body or relative parent relationship in case of specimen processing | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| | CONF | | 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" | | @codeSystemName shall be "SCT" | | @displayName shall be "all children of Body structure (body structure)" | | or | | @code shall be "any_code" | | @codeSystem shall be "2.16.840.1.113883.5.1052" | | @codeSystemName shall be "ActSite" | | @displayName shall be "any_code" |
|
| | Example | for use case #1, specimen collection <targetSiteCode code="110497008" displayName="Lower outer quadrant of right breast (body structure)" codeSystem="2.16.840.1.113883.6.96"/> |
| | Example | for use case #1, grossing & embedding <targetSiteCode code="309050000" displayName="Body substance sample" codeSystem="2.16.840.1.113883.6.96"/> |
| | hl7:qualifier
|
| CR CWE | 0 … * | C | optional qualifiers for specifying body structures or / and laterality | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| | Example | for use case #1, (optional) 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> |
| CV CWE | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| st | 0 … 1 | F | Specimen source topography |
| oid | 1 … 1 | F | 2.16.840.1.113883.6.96 |
| cs | 1 … 1 | F | 118169006 |
| CD CWE | 0 … * | R | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| CONF | 1 … 1 | | @code shall be out of choice:- <<272099008
- Descriptor (qualifier value)
|
| 1 … 1 | F | 2.16.840.1.113883.6.96 (SNOMED Clinical Terms) |
| 1 … 1 | F | SCT |
| 1 … 1 | F | all children of "Descriptor, qualifier values", e.g. right lower quadrantt |
| hl7:methodCode
|
| CD CWE | 0 … * | | Identifies the technique used to perform a procedure
| PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| | @codeSystem
|
| cs | 1 … 1 | F | 2.16.840.1.113883.5.1065 |
| Included | 0 … 1 | R | from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC)
Parent specimen with parent ID |
| | Example | for use case #1, parent specimen ID in grossing & embedding <specimen typeCode="SPC">
<specimenRole classCode="SPEC">
<!-- Parent specimen ID -->
<id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008"/> </specimenRole></specimen> |
| hl7:specimen
|
| | 0 … 1 | 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 |
| | hl7:specimenRole
|
| | 1 … 1 | M | | PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified |
| cs | 0 … 1 | F | SPEC |
| II | 1 … 1 | R | Specimen ID, coming from the LIS | PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified |
| hl7:performer
|
| | 0 … 1 | R | 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 |
| hl7:author
|
| | 0 … * | C | Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (DYNAMIC) | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| hl7:participant
|
| | 1 … * | M | One 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 |
| where [not(@nullFlavor)] |
| |
| hl7:entryRelationship
|
| | 0 … * | R | Artificial 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 |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | Constraint | for manufactured product
classCode = MANU
for DrugOrOtherMaterial
classCode = MMAT
code from MaterialEntityClassType
|
| hl7:entryRelationship
|
| | 0 … 1 | R | Specimen 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 |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | Constraint | |
| hl7:entryRelationship
|
| | 0 … * | R | Referencing mechanism to the ID of the child procedures, giving a lis of child procedure IDs
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 |
| | @typeCode
|
| cs | 1 … 1 | F | REFR |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | Constraint | contains only ID of the child procedure, which is fully described in a dedicated entry further down in the Procedure step section. |
Draft
