| Item | DT | Card | Conf | Description | Label |
|---|
| | 0 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
 | @classCode
|
| cs | 0 … 1 | F | DOCSECT |
| @moodCode
|
| cs | 0 … 1 | F | EVN |
| | Constraint | This section SHALL contain a code element populated with these attributes:
@code="22636-5"
@codeSystem="'2.16.840.1.113883.6.1"
@displayName=" Pathology report relevant history”
This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.
The section SHOULD contain as many Problem Organizer entry elements as there are problems (or groups thereof) to be described. These entries provide the machine-readable data corresponding to the narrative block.
This section MAY contain a number of elements component/section introducing sub-sections, each of these sub-sections providing a particular type of clinical information.
This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.
|
| |  | Associated with concepts:| psr-dataelement-40 | Clinical Information | APSR 2.0 |
|
| hl7:templateId
|
| II | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
 | | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.8.1.2.1 |
| hl7:code
|
| CE | 1 … 1 | M | | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
| | @code
|
| CONF | 1 … 1 | F | 22636-5 |
| | @codeSystem
|
| 1 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) |
| | @displayName
|
| 1 … 1 | F | Pathology report relevant history |
| | @codeSystemName
|
| 1 … 1 | F | LOINC |
| hl7:title
|
| ST | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
| | CONF | | element content shall be "CLINICAL INFORMATION SECTION" |
|
| | Example | <title>CLINICAL INFORMATION</title> |
| hl7:text
|
| SD.TEXT | 1 … 1 | M | | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
| | Example | <text> Tissue submitted: left breast biopsy and apical axillary tissue </text> |
| hl7:languageCode
|
| CS | 0 … 1 | | | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC) |
|
| hl7:entry
|
| ANY | 0 … * | R | Problem organizer
Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (DYNAMIC) | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
| | @typeCode
|
| cs | 0 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| Included | 0 … * | C | from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author (DYNAMIC)
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2
|
| hl7:author
|
| | 0 … * | C | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | @typeCode
|
| cs | 0 … 1 | F | AUT |
| | @contextControlCode
|
| cs | 0 … 1 | F | OP |
| | | Associated with concepts:| psr-dataelement-4 | Pathologist | APSR 2.0 | | psr-dataelement-79 | Device | APSR 2.0 |
|
| | Example | author is a person <author typeCode="AUT" contextControlCode="OP">
<time value="201306101654"/> <assignedAuthor classCode="ASSIGNED">
<!-- ... -->
</assignedAuthor></author> |
| | hl7:functionCode
|
| CE | 0 … 1 | | | PaLM 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) |
|
| | hl7:time
|
| TS.DATE.MIN | 1 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | hl7:assignedAuthor
|
| | 1 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| cs | 0 … 1 | F | ASSIGNED |
| II | 1 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| CE | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| TEL | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| Choice | 1 … 1 | | Elements to choose from:- hl7:assignedPerson
- hl7:assignedAuthoringDevice
|
| | … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| Included | 0 … * | | from 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC) |
| | 0 … 1 | F | PSN |
| | 0 … 1 | F | INSTANCE |
| PN | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | | | hl7:assignedAuthoringDevice
|
| | … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| cs | 0 … 1 | F | DEV |
| cs | 0 … 1 | F | INSTANCE |
| | | | | hl7:manufacturerModelName
|
| SC | 1 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| SC | 1 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | | hl7:representedOrganization
|
| | 1 … 1 | M | | PaLM 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) |
| | 0 … 1 | F | ORG |
| | 0 … 1 | F | INSTANCE |
| II | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| ON | 1 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| TEL | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| AD | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| hl7:component
|
| | 0 … 1 | | Subsection
Source: PCC TF-2: 6.3.3.1.1
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.1 IHE Reason for Referral Section (DYNAMIC) | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
| | | Associated with concepts:| psr-dataelement-41 | Reason for Referral | APSR 2.0 |
|
| hl7:component
|
| | 0 … 1 | | Subsection
Source: PCC TF-2: 6.3.3.2.1
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (DYNAMIC) | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
| | | Associated with concepts:| psr-dataelement-42 | History of Present Illness | APSR 2.0 |
|
| hl7:component
|
| | 0 … 1 | | Subsection
Source: PCC TF-2: 6.3.3.2.3
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.6 IHE Active Problems Section (DYNAMIC) | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
| | | Associated with concepts:| psr-dataelement-43 | Clinical Problem | APSR 2.0 |
|
Draft
