1.3.6.1.4.1.19376.1.3.10.4.1/static-2016-07-08T132059

Id	1.3.6.1.4.1.19376.1.3.10.4.1	Effective 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
Status	Draft	Version Label	2.0
Name	SpecimenProcedureStep	Display Name	Specimen Procedure Step
Description Template 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.
Label	PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 4 templates, Uses 7 templates Used by as Name Version 1.3.6.1.4.1.19376.1.3.10.4.1 Containment Specimen Procedure Step (2.0) 2016‑07‑08 13:20:59  Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check 1.3.6.1.4.1.19376.1.3.10.4.1 Specimen Procedure Step (1.0) 2014‑07‑29 16:02:02  Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check 1.3.6.1.4.1.19376.1.8.1.2.6 Procedure Steps Section (2.0) 2014‑05‑13 19:33:12 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 Uses as Name Version 1.3.6.1.4.1.19376.1.3.10.9.1 Include X Specimen Identified DYNAMIC 1.3.6.1.4.1.19376.1.3.3.1.7 Containment Laboratory Performer (2008) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.4.2 Containment CDA author IHE DYNAMIC 1.3.6.1.4.1.19376.1.3.10.9.20 Containment CDA Participant (Body) Procedure Steps APSR2 (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.3.10.9.22 Containment CDA Supply Container APSR2 (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.3.1.3 Containment Specimen Received (2008) DYNAMIC 1.3.6.1.4.1.19376.1.3.10.4.1 Containment Specimen Procedure Step (2.0) DYNAMIC
Relationship	Adaptation: template 2.16.840.1.113883.10.12.306 (2005‑09‑07)
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 code="23307004" codeSystem="2.16.840.1.113883.6.96" displayName="Estrogen receptor (substance)"/>    </qualifier>  </code>  <text/>  <statusCode code="completed"/>  <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>
Item DT Card Conf Description Label hl7:procedure 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> hl7:name CV CWE 1 … 1 R PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps @code cs 0 … 1 F 246094008_or_246355002 @codeSystem oid 0 … 1 F 2.16.840.1.113883.6.96 @displayName st 0 … 1 F Component investigated (attribute) or Supporting structure (attribute) hl7:value CD CWE 1 … 1 R PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps @nullFlavor 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: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:target​Site​Code 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> hl7:name CV CWE 1 … 1 R PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps @displayName st 0 … 1 F Specimen source topography @codeSystem oid 1 … 1 F 2.16.840.1.113883.6.96 @code cs 1 … 1 F 118169006 hl7:value CD CWE 0 … * R PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps @code CONF 1 … 1   @code shall be out of choice: <<272099008 Descriptor (qualifier value) @codeSystem 1 … 1 F 2.16.840.1.113883.6.96 (SNOMED Clinical Terms) @codeSystemName 1 … 1 F SCT @displayName 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 @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 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 @context​Conduction​Ind 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 @context​Conduction​Ind 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 @context​Conduction​Ind 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.