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Version vom 18. Oktober 2017, 02:59 Uhr

Id1.3.6.1.4.1.19376.1.3.10.4.4Effective 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
StatusKyellow.png DraftVersion Label2.0
NameAssessmentScalesObservationScoringSystemsAPSRDisplay NameAssessment 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
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.4
LabelPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
ClassificationCDA Entry Level Template
Open/ClosedClosed (only defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 7 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.3.10.4.3ContainmentKyellow.png ICD-O-3 Typing and Grading Observation (2.0)2015‑11‑29 17:03:18
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA author IHEDYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.7ContainmentKyellow.png Additional participant in an entry APSR (Body)DYNAMIC
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen IdentifiedDYNAMIC
1.3.6.1.4.1.19376.1.3.10.9.42ContainmentKyellow.png Assessment Scoring System APSR 2.0 (2.0)DYNAMIC
2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA ReferenceDYNAMIC
RelationshipSpecialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 (2014‑05‑14 17:09:54)
Example
example for use case #1, ER-Allred Score
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <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="sum"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20170711113628"/>  </effectiveTime>  <priorityCode code="R" displayName="routine" codeSystem="2.16.840.1.113883.5.7"/>  <repeatNumber/>  <value xsi:type="PQ" value="8"/>  <interpretationCode code="RR" displayName="Reactive" codeSystem="2.16.840.1.113883.5.83"/>  <methodCode code="0114" codeSystem="2.16.840.1.113883.1.11.14079" displayName="Microscopy, Light"/>  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (dynamic) -->
  </performer>  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (dynamic) -->
  </author>  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (dynamic) -->
  </informant>  <participant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (dynamic) -->
  </participant>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 0..* R -->
  <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>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … 1RPaLM…ales
Treetree.png@classCode
cs0 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1MPaLM…ales
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.4.4
Treetree.pnghl7:id
II0 … *RPaLM…ales
Treetree.pnghl7:code
CE CWE1 … 1MAssessment scale, e.g. grading by scoringPaLM…ales
 CONF
@code shall be "273249006"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SCT"
@displayName shall be "Assessment scales"
or
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19918 ActCoverageAssessmentObservationValue (DYNAMIC)
 Example
for use case #1
<code code="273249006" codeSystem="2.16.840.1.113883.6.96" displayName="Assessment scales (assessment scale)"/>
Treetree.pnghl7:derivationExpr
ST0 … 1RThis 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…ales
Treetree.pnghl7:text
ED0 … 1RPaLM…ales
 Example
for use case #1
<text>Nottingham combined grad I (1 of 3)</text>
Treetree.pnghl7:statusCode
CS1 … 1MPaLM…ales
 ConstraintThe observation statusCode is “completed” if the observation was actually performed and has produced a result in the value element. In other cases the status of the intended observation is “aborted” and the result will never come.
 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_TS1 … 1MPaLM…ales
Treetree.pnghl7:priorityCode
CE0 … 1PaLM…ales
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
Treetree.pnghl7:repeatNumber
IVL_INT0 … 1PaLM…ales
Treetree.pnghl7:value
ANY1 … *Rany total value of a scoring systems, e.g. Gleason score, van Nuys score, etc., either with data type INT or with data type CD or CO 
PaLM…ales
 Example
for use case #1, Nottingham combined grade I
<value value="1"/>
Treetree.pnghl7:interpretationCode
CE0 … *RPaLM…ales
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)
Treetree.pnghl7:methodCode
CE0 … *RPaLM…ales
Treeblank.pngTreetree.png@code
CONF1 … 1F0114
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.1.11.14079
Treeblank.pngTreetree.png@codeSystemName
1 … 1FHL7
Treeblank.pngTreetree.png@displayName
1 … 1FMicroscopy, Light
Treetree.pnghl7:performer
II0 … 1CPerforming lab

Source: PaLM TF-3: 6.3.2.20

Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC)		PaLM…ales
 ConstraintThe performing laboratory is present at this level only if this particular observation was performed by a (subcontractor) laboratory distinct from the one issuing the rest of the observations in this organizer.
Treetree.pnghl7:author
II0 … *CAuthor

Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.2

Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (DYNAMIC)		PaLM…ales
Treetree.pnghl7:informant
II0 … *RInformant

Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.5

Contains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (DYNAMIC)		PaLM…ales
Treetree.pnghl7:participant
II0 … *RAdditional participants

Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.6

Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry APSR (Body) (DYNAMIC)		PaLM…ales
Included0 … *R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC)
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
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
Treetree.pnghl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.10.9.42 Assessment Scoring System APSR 2.0 (DYNAMIC)PaLM…ales
Treeblank.png where [hl7:observation [hl7:code [(@code='246262008 or
Score (attribute) or
' and @codeSystem='2.16.840.1.113883.6.96')]]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1PaLM…ales
Treetree.pnghl7:reference
0 … *RContains 2.16.840.1.113883.10.12.324 CDA Reference (DYNAMIC)PaLM…ales
Treetree.pnghl7:referenceRange
0 … *RPaLM…ales
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFV
Treeblank.pngTreetree.pnghl7:observationRange
1 … 1RPaLM…ales
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FOBS
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs0 … 1FEVN.CRT
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CD0 … 1PaLM…ales
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF1 … 1F2.16.840.1.113883.5.4
Treeblank.pngTreeblank.pngTreetree.pnghl7:text
ED0 … 1PaLM…ales
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
ANY0 … 1PaLM…ales
Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretationCode
CE0 … 1PaLM…ales
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)
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