1.3.6.1.4.1.19376.1.8.1.2.5/static-2014-05-13T193126

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Id1.3.6.1.4.1.19376.1.8.1.2.5Effective Date valid from 2014‑05‑13 19:31:26
StatusKyellow.png DraftVersion Label2.0
NameDiagnosticConclusionSectionDisplay NameDiagnostic Conclusion Section
DescriptionThe Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.5
LabelPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
ClassificationCDA Section Level Template
Open/ClosedClosed (only defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
psr-data​element-3Tumor formula (TNM)APSR 2.0
psr-data​element-54Tumor classification (ICD-O-3)APSR 2.0
psr-data​element-45DiagnosisAPSR 2.0
Used by / Uses
Used by 1 template, Uses 2 templates
Used by Template id as NameVersion
1.3.6.1.4.1.19376.1.8.1.1.1ContainmentKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses Template id as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA authorDYNAMIC
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example
generated example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.5"/>  <code code="22637-3" codeSystem="2.16.840.1.113883.6.1" displayName="'Pathology report diagnosis"/>  <title>Diagnostic conclusion</title>  <text/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) 0..* C -->
  <entry>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (dynamic) -->
  </entry></section>
ItemDTCardConfDescriptionLabel
hl7:section
1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
Treetree.png@classCode
cs1 … 1FDOCSECT
Treetree.png@moodCode
cs1 … 1FEVN
 Constraint

This section SHALL contain a code element populated with these attributes:

@code="22637-3"

@codeSystem="2.16.840.1.113883.6.1"

@displayName="Pathology report diagnosis" 

This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.

The section SHALL contain as many Problem Organizer entry elements as there are problems or groups thereof investigated. Each entry provides machine-readable data.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

 Target.pngAssociated with concepts:
psr-data​element-3Tumor formula (TNM)APSR 2.0
psr-data​element-54Tumor classification (ICD-O-3)APSR 2.0
psr-data​element-45DiagnosisAPSR 2.0
Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
Treeblank.pngTreetree.png@root
uid0 … 1F1.3.6.1.4.1.19376.1.8.1.2.5
Treetree.pnghl7:code
CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
Treeblank.pngTreetree.png@code
CONF1 … 1F22637-3
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@displayName
1 … 1F'Pathology report diagnosis
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treetree.pnghl7:title
ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
 CONF
element content shall be "Diagnostic conclusion"
Treetree.pnghl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
 Example
Diagnosis
<text> Invasive breast cancer, no special type TNM: pT1c pN0(0/3sn) L0 V0 R0 G2 ICD-O-3: 8500/3 </text>
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author (DYNAMIC)
Author

Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2
Treetree.pnghl7:author
0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.png@typeCode
cs0 … 1FAUT
Treeblank.pngTreetree.png@context​Control​Code
cs0 … 1FOP
 Target.pngAssociated with concepts:
psr-data​element-4PathologistAPSR 2.0
psr-data​element-79DeviceAPSR 2.0
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor></author>
Treeblank.pngTreetree.pnghl7:functionCode
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
Treeblank.pngTreetree.pnghl7:time
TS.​DATE.​MIN1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 Example
author is a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name></representedOrganization>
Included from 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treetree.pnghl7:entry
0 … *RSource: PaLM Suppl. APSR 2.0-3: 6.2.5.2

Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (DYNAMIC)		PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
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