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Template ZusammenfassungSection

Beschreibung

Die Zusammenfassung-Section besteht aus mehreren Unter-Sections, welche die zusammenfassende Interpretation der verschiedenen durchgeführten Tests als auch Indikation, Bemerkungen und Informationen zum Probenmaterial enthalten.

Aktuelle Version

Id	2.16.840.1.113883.2.6.60.13.10.13	Gültigkeit	2018‑10‑25 12:04:03
Status	Entwurf	Versions-Label
Name	ZusammenfassungSection	Bezeichnung	Zusammenfassung Section
Beschreibung Die Zusammenfassung-Section besteht aus mehreren Unter-Sections, welche die zusammenfassende Interpretation der verschiedenen durchgeführten Tests als auch Indikation, Bemerkungen und Informationen zum Probenmaterial enthalten.
Kontext	Elternknoten des Template-Element mit Id 2.16.840.1.113883.2.6.60.13.10.13
Klassifikation	CDA Section level template
Offen/Geschlossen	Offen (auch andere als die definierten Elemente sind erlaubt)
Benutzt	Benutzt 5 Templates Benutzt als Name Version 2.16.840.1.113883.2.6.60.13.10.9 Containment Indikation Section DYNAMIC 2.16.840.1.113883.2.6.60.13.10.8 Containment Zusammenfassung Durchgeführte Untersuchungen Section DYNAMIC 2.16.840.1.113883.2.6.60.13.10.10 Containment Zusammenfassende Interpretation Section DYNAMIC 2.16.840.1.113883.2.6.60.13.10.14 Containment Empfehlungen Section DYNAMIC 2.16.840.1.113883.2.6.60.13.10.17 Containment Untersuchungsmaterial Section DYNAMIC
Beziehung	Adaptation: Template 2.16.840.1.113883.10.20.20.1.1 Summary Section (2013‑02‑01) ref gtr- Spezialisierung: Template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07) ref ad1bbr-
Beispiel	Beispiel <section>   <templateId root="2.16.840.1.113883.10.20.20.1.1"/>  <title>Summary</title>  <component>     <section>       <templateId root="2.16.840.1.113883.10.20.20.1.11"/>      <title>Indications</title>      <text>         <list>           <item>             <content ID="a2">Indication: Profound sensorineural hearing loss</content>          </item>        </list>      </text>      <entry>         <observation classCode="COND" moodCode="EVN">           <templateId root="2.16.840.1.113883.10.20.20.3.3.1"/>          <id root="2.16.840.1.113883.18.12.7.30.9.2.1"/>          <code code="51967-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Genetic disease assessed"/>          <value xsi:type="CD" code="85571008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Sensory Hearing Loss">             <originalText>               <reference value="#a2"/>            </originalText>          </value>          <reference typeCode="XCRPT">             <externalObservation>               <id root="2.16.840.1.113883.19.1.2765"/>            </externalObservation>          </reference>        </observation>      </entry>    </section>  </component>  <component>     <section>       <templateId root="2.16.840.1.113883.10.20.20.1.1.6"/>      <title>Summary of Tests Performed</title>      <text>         <list>           <item>             <content ID="a1"> GJB2 Full Gene Test </content>          </item>          <item>             <content ID="a5"> GJB6-D13S1830 deletion </content>          </item>          <item>             <content ID="a3"> Mitochondrial Hearing Loss Mutation Test </content>          </item>        </list>      </text>    </section>  </component>  <component>     <section>       <templateId root="2.16.840.1.113883.10.20.20.1.1.1"/>      <title>Overall Interpretation</title>      <text>         <list>           <item>             <content styleCode="Bold">Inconclusive.</content>          </item>          <item>             <content> DNA sequencing detected two changes in the GJB2 gene, 79G>A (V27I) and 109G>A (V37I). The V27I change has been reported as a benign variant (references) and is not believed to cause hearing loss. The V37I mutation has been previously reported in patients with hearing loss. This mutation, in homozygosity or combined with another GJB2 disease causing mutation, typically results in a mild to moderate hearing loss (Cryns et al. 2005). Mutations in both copies of the GJB2 gene are necessary to assume that GJB2 is responsible for the hearing loss. Although two mutations were identified in this patient, we would assume that the combination of a benign variant and a mild pathogenic mutation would result in a mild to moderate hearing loss rather than a moderately-severe one, as in this patient. It is most likely that the hearing loss in this patient is the result of the V37I mutation and an unknown second pathogenic mutation. It should be noted that a second mutation is not identified in a large percentage (10-50%) of patients with nonsyndromic hearing loss and GJB2 mutations (del Castillo et al. 2003). </content>          </item>          <item>             <content> GJB6-D13S1830 Deletion: A PCR-based analysis of the GJB6-D13S1830 region of chromosome 13 was performed and did not detect the deletion. This test does not assess the DNA sequence of the GJB6 gene or detect other mutations that could affect the expression of the gene. </content>          </item>          <item>             <content> Mitochondrial Hearing Loss mutations: Targeted bidirectional sequencing of mitochondrial DNA 1555 and 7445 regions did not detect the presence of these mutations. </content>          </item>        </list>      </text>      <entry>         <observation classCode="OBS" moodCode="EVN">           <templateId root="2.16.840.1.113883.10.20.20.2.4"/>          <id root="2.16.840.1.113883.18.12.7.30.9.1.2"/>          <code code="55232-3" codeSystemName="LOINC" displayName="Genetic analysis summary panel"/>          <statusCode code="completed"/>          <entryRelationship typeCode="SUBJ">             <organizer classCode="BATTERY" moodCode="EVN">               <templateId root="2.16.840.1.113883.10.20.20.5.1"/>              <statusCode code="completed"/>              <component>                 <observation classCode="OBS" moodCode="EVN">                   <templateId root="2.16.840.1.113883.10.20.20.6"/>                  <id root="2.16.840.1.113883.18.12.7.30.9.8.1"/>                  <code/>                </observation>              </component>              <component>                 <observation classCode="OBS" moodCode="EVN">                   <templateId root="2.16.840.1.113883.10.20.20.6"/>                  <id root="2.16.840.1.113883.18.12.7.30.9.8.2"/>                  <code/>                </observation>              </component>              <component>                 <observation classCode="OBS" moodCode="EVN">                   <templateId root="2.16.840.1.113883.10.20.20.6"/>                  <id root="2.16.840.1.113883.18.12.7.30.9.8.3"/>                  <code/>                </observation>              </component>              <component>                 <observation classCode="OBS" moodCode="EVN">                   <templateId root="2.16.840.1.113883.10.20.20.6"/>                  <id root="2.16.840.1.113883.18.12.7.30.9.8.4"/>                  <code/>                </observation>              </component>            </organizer>          </entryRelationship>          <entryRelationship typeCode="RSON">             <observation classCode="COND" moodCode="EVN">               <templateId root="2.16.840.1.113883.10.20.20.6"/>              <id root="2.16.840.1.113883.18.12.7.30.9.2.1"/>              <code/>            </observation>          </entryRelationship>          <entryRelationship typeCode="SPRT">             <observation classCode="OBS" moodCode="DEF">               <templateId root="2.16.840.1.113883.10.20.20.2.5.5"/>              <code code="51968-6" codeSystemName="LOINC" displayName="Genetic disease analysis overall interpretation"/>              <statusCode code="completed"/>              <effectiveTime value="200512011500"/>              <value xsi:type="CD" code="LA9663-1" displayName="Inconclusive"/>              <performer typeCode="PRF">                 <assignedEntity>                   <id root="2.16.840.1.113883.19.3.2409.345"/>                  <representedOrganization>                     <name>The New Genetic Testing Analysis Service</name>                  </representedOrganization>                </assignedEntity>              </performer>            </observation>          </entryRelationship>        </observation>      </entry>    </section>  </component>  <component>     <section>       <templateId root="2.16.840.1.113883.10.20.20.1.1.5"/>      <title>Recommendations</title>      <text>         <list>           <item>             <content> Although some cases may represent a coincidental carrier state, all of the studies have concluded that there are likely to be other genetic mutations that have not yet been identified. Genetic counseling is recommended for this patient and his/her family members. </content>          </item>        </list>      </text>    </section>  </component>  <component>     <section>       <templateId root="2.16.840.1.113883.10.20.20.1.7"/>      <title>Specimen and Genomic Source Class</title>      <text>         <list>           <item>Peripheral Blood</item>          <item>Genomic source class: Germline</item>        </list>      </text>      <entry>         <observation classCode="OBS" moodCode="EVN">           <templateId root="2.16.840.1.113883.10.20.20.3.2"/>          <id root="2.16.840.1.113883.18.12.7.30.9.3.7"/>          <code code="48002-0" codeSystemName="LOINC" displayName="Genomic source class"/>          <value xsi:type="CD" code="LA6683-2" codeSystemName="LOINC" displayName="Germline"/>          <specimen>             <templateId root="2.16.840.1.113883.10.20.20.3.1"/>            <specimenRole>               <specimenPlayingEntity>                 <code code="180796014" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Peripheral blood specimen"/>              </specimenPlayingEntity>            </specimenRole>          </specimen>        </observation>      </entry>    </section>  </component></section>
Item DT Kard Konf Beschreibung Label hl7:section (Zus...ion)   Constraint Unterabschnitte des Abschnitts SummarySection SOLLTEN in der in diesem Implementierungsleitfaden angegebenen Reihenfolge angezeigt werden. hl7:templateId II 1 … 1 M (Zus...ion) @root uid 1 … 1 F 2.16.840.1.113883.2.6.60.13.10.13 hl7:code 0 … 1 R (Zus...ion)   Constraint Gtr Summary Section KANN einen Code enthalten, der die Zusammenfassung aller in diesem Dokument beschriebenen Gentests darstellt. hl7:title ST 1 … 1 R (Zus...ion)   CONF Elementinhalt muss "Zusammenfassung" sein hl7:section 0 … 1 R Beinhaltet 2.16.840.1.113883.2.6.60.13.10.9 Indikation Section (DYNAMIC) (Zus...ion) hl7:section 0 … 1 R Beinhaltet 2.16.840.1.113883.2.6.60.13.10.8 Zusammenfassung Durchgeführte Untersuchungen Section (DYNAMIC) (Zus...ion) hl7:section 0 … 1 R Beinhaltet 2.16.840.1.113883.2.6.60.13.10.10 Zusammenfassende Interpretation Section (DYNAMIC) (Zus...ion) hl7:section 0 … 1 R Beinhaltet 2.16.840.1.113883.2.6.60.13.10.14 Empfehlungen Section (DYNAMIC) (Zus...ion) hl7:section 0 … 1 Beinhaltet 2.16.840.1.113883.2.6.60.13.10.17 Untersuchungsmaterial Section (DYNAMIC) (Zus...ion)

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• 2018-10-25 12:04:03 (In Entwicklung)