| Item | DT | Card | Conf | Description | Label |
|---|
| | 1 … * | 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 |
| @negationInd
|
| bl | 0 … 1 | | |
| |  | Associated with concepts:| psr-dataelement-24 | Specimen collection | APSR 2.0 | | psr-dataelement-25 | Specimen processing | APSR 2.0 | | psr-dataelement-90 | Requested Procedure | APSR 2.0 |
|
| 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 | 1 … 1 | M | 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 |
| | | Associated with concepts:| psr-dataelement-87 | Procedure ID | APSR 2.0 | | psr-dataelement-89 | Procedure Step | APSR 2.0 |
|
| 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) |
|
| | hl7:qualifier
|
| CR | 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 | Estrogen receptor <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 | ISH Her-2-neu <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 | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| cs | 0 … 1 | F | 246094008 or 246355002 |
| cs | 0 … 1 | F | 2.16.840.1.113883.6.96 |
| cs | 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 "values from substance axis" | | @codeSystem shall be "2.16.840.1.113883.6.96" | | @displayName shall be "e.g. Estrogen receptor" | | @codeSystemName shall be "SNOMED-CT" | | or | | @code shall be "values from G axis" | | @codeSystem shall be "2.16.840.1.113883.6.174" | | @displayName shall be "e.g. erb-b2" | | @codeSystemName shall be "OMIM" | | or | | @code shall be "values from technique axis" | | @codeSystem shall be "2.16.840.1.113883.6.96" | | @displayName shall be "e.g. Paraffin embedded (qualifier)" | | @codeSystemName shall be "SNOMED-CT" |
|
| 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:targetSiteCode
|
| CD CWE | 0 … * | 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 | | @codeSystem shall be "2.16.840.1.113883.5.1052" | | or | | 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 "all children of 123037004" | | @codeSystem shall be "2.16.840.1.113883.6.96" | | @displayName shall be "all children of Body structure (body structure)" | | @codeSystemName shall be "SCT" |
|
| | | Associated with concepts:| psr-dataelement-94 | Target Site | APSR 2.0 |
|
| | hl7:qualifier
|
| CR | 0 … * | | optional qualifiers for specifying body structures or / and laterality | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| | Example | 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 | 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 | F | all children of "362981000" |
| 1 … 1 | F | 2.16.840.1.113883.6.96 (SNOMED Clinical Terms) |
| 1 … 1 | F | all children of "qualifier values" |
| 1 … 1 | F | SCT |
| hl7:methodCode
|
| CD | 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 … * | | from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC)
Parent specimen with parent ID |
| hl7:specimen
|
| | 0 … * | R | Required when more than one specimen is documented at this level. This is often the case 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-dataelement-17 | Specimen identification | APSR 2.0 |
|
| | 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 |
| | | Associated with concepts:| psr-dataelement-68 | Tissue section ID | APSR 2.0 | | psr-dataelement-98 | Specimen ID | APSR 2.0 | | psr-dataelement-66 | Part ID | APSR 2.0 | | psr-dataelement-67 | Block ID | APSR 2.0 | | psr-dataelement-95 | Parent ID | APSR 2.0 |
|
| hl7:performer
|
| | 0 … * | | Contains 1.3.6.1.4.1.19376.1.3.3.1.7 CDA Performer IHE (Body) (DYNAMIC) | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| hl7:author
|
| | 0 … * | | Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author (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 |
| | @inversionInd
|
| bl | 0 … 1 | | |
| | @negationInd
|
| bl | 0 … 1 | | |
| | Constraint | for manufactured product
classCode = MANU
for DrugOrOtherMaterial
classCode = MMAT
code from MaterialEntityClassType
|
| | hl7:seperatableInd
|
| BL | 0 … * | | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| 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 |
| | @inversionInd
|
| bl | 0 … 1 | | |
| | @negationInd
|
| bl | 0 … 1 | | |
| | Constraint | |
| | hl7:seperatableInd
|
| BL | 0 … * | | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| | hl7:sequenceNumber
|
| INT | 0 … * | | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
| hl7:entryRelationship
|
| | 0 … 4 | R | Referencing mechanism to the ID of the parent procedure
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 |
| | @inversionInd
|
| bl | 0 … 1 | | |
| | @negationInd
|
| bl | 0 … 1 | | |
| | Constraint | contains only ID of the child procedure, which is fully described in a dedicated entry further down in the Procedure step section. |
| | hl7:seperatableInd
|
| BL | 0 … * | | | PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps |
Draft
