1.3.6.1.4.1.19376.1.3.10.9.42/static-2016-10-10T113336

Id	1.3.6.1.4.1.19376.1.3.10.9.42	Effective Date	valid from 2016‑10‑10 11:33:36
Status	Draft	Version Label	2.0
Name	AssessmentScoringSystemAPSR2.0	Display Name	Assessment Scoring System APSR 2.0
Description	Template CDA Observation (prototype, directly derived from PO.0CD_RM000040 MIF) Supportive Observation entry for describing a scoring system
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.42
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 10 templates, Uses 4 templates Used by Template id as Name Version 1.3.6.1.4.1.19376.1.3.10.4.4 Containment Assessment Scales Observation for Scoring Systems APSR2 (2.0) 2016‑10‑06 13:12:00 1.3.6.1.4.1.19376.1.3.10.4.3 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 1.3.6.1.4.1.19376.1.3.10.9.43 Containment Assessment Scoring Item APSR 2.0 (2.0) DYNAMIC 2.16.840.1.113883.10.12.324 Containment CDA Reference DYNAMIC 2.16.840.1.113883.10.12.329 Containment CDA Precondition DYNAMIC
Relationship	Adaptation: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Example	generated example for use case #1 <observation negationInd="false" classCode="OBS" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.3.10.9.42"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="246262008 | Score (attribute) |" codeSystem="2.16.840.1.113883.6.96" displayName="Score"/>  <derivationExpr/>  <text/>  <statusCode code="completed"/>  <effectiveTime>     <low value="20170224134516"/>  </effectiveTime>  <value code="372276001" codeSystem="2.16.840.1.113883.6.96" displayName="Nottingham Combined Grade (observable entity)"/>  <methodCode code="0107" displayName="Microscopy" codeSystem="2.16.840.1.113883.5.84"/>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 1..* R -->   <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">     <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.43 'Assessment Scoring Item APSR 2.0' (dynamic) -->   </entryRelationship>  <reference>     <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (dynamic) -->   </reference>  <precondition>     <!-- template 2.16.840.1.113883.10.12.329 'CDA Precondition' (dynamic) -->   </precondition>  <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 (AssessmentScoringSystemAPSR2.0) @classCode cs 0 … 1 F OBS @moodCode cs 1 … 1 F EVN @negationInd bl 0 … 1   hl7:templateId II 1 … 1 M (AssessmentScoringSystemAPSR2.0) @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.10.9.42 hl7:id II 0 … * (AssessmentScoringSystemAPSR2.0) hl7:code CV CWE 1 … 1 R (AssessmentScoringSystemAPSR2.0) @code CONF 1 … 1   @code shall be out of choice: 246262008 Score (attribute) @codeSystem 1 … 1 F 2.16.840.1.113883.6.96 (SNOMED Clinical Terms) @displayName 1 … 1 F Score @codeSystemName 1 … 1 F SCT 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. (AssessmentScoringSystemAPSR2.0) hl7:text ED 0 … 1 Scoring system used (AssessmentScoringSystemAPSR2.0) hl7:statusCode CS CNE 1 … 1 R (AssessmentScoringSystemAPSR2.0)   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 (AssessmentScoringSystemAPSR2.0) hl7:value CE CWE 1 … 1 R (AssessmentScoringSystemAPSR2.0)   CONF @code shall be "any codes from 395531003 | Tumor observable (observable entity) |" @codeSystem shall be "2.16.840.1.113883.6.96" @displayName shall be "any score systems from Tumor observables" @codeSystemName shall be "SCT" or @code shall be "any codes from 273249006 | Assessment scales" @codeSystem shall be "2.16.840.1.113883.6.96" @displayName shall be "any score systems from Assessment scales" @codeSystemName shall be "SCT" hl7:methodCode CE 0 … * (AssessmentScoringSystemAPSR2.0)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (DYNAMIC) Included 1 … * R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC) hl7:specimen 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   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 … * R Contains 1.3.6.1.4.1.19376.1.3.10.9.43 Assessment Scoring Item APSR 2.0 (DYNAMIC) (AssessmentScoringSystemAPSR2.0) @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true @inversionInd bl 0 … 1   @negationInd bl 0 … 1   hl7:sequenceNumber INT 0 … 1 (AssessmentScoringSystemAPSR2.0) hl7:seperatableInd BL 0 … 1 (AssessmentScoringSystemAPSR2.0) hl7:reference 0 … * Contains 2.16.840.1.113883.10.12.324 CDA Reference (DYNAMIC) (AssessmentScoringSystemAPSR2.0) hl7:precondition 0 … * Contains 2.16.840.1.113883.10.12.329 CDA Precondition (DYNAMIC) (AssessmentScoringSystemAPSR2.0) hl7:referenceRange 0 … * (AssessmentScoringSystemAPSR2.0) @typeCode cs 1 … 1 F REFV hl7:observationRange 1 … 1 R (AssessmentScoringSystemAPSR2.0) @classCode cs 0 … 1 F OBS @moodCode cs 0 … 1 F EVN.CRT hl7:code CD 0 … 1 R (AssessmentScoringSystemAPSR2.0) @codeSystem CONF 1 … 1 F 2.16.840.1.113883.5.4 (Act Code) hl7:text ED 0 … 1 R (AssessmentScoringSystemAPSR2.0) hl7:value ANY 0 … 1 R (AssessmentScoringSystemAPSR2.0) hl7:interpretationCode CE 0 … 1 (AssessmentScoringSystemAPSR2.0)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 Observation Interpretation (HL7) (DYNAMIC)