1.3.6.1.4.1.19376.1.8.1.1.1/static-2014-05-13T115757

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Id1.3.6.1.4.1.19376.1.8.1.1.1Effective Date valid from 2014‑05‑13 11:57:57
StatusKyellow.png DraftVersion Label2.0
NameAnatomicPathologyStructuredReportContentModuleDisplay NameAnatomic Pathology Structured Report Content Module
Description
Anatomic Pathology Structured Report Content Module. 

This document content module represents the generic set of constraints applied to any structured report for surgical pathology in all fields of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as for Cytopathology. 

The body of this Document Content Module specifies a common hierarchy of sections and entries depicted by figure 10.4.1-1 in Volume 1 IHE_PaLM_Suppl_APSR 2.0. The only mandatory section is the Diagnostic Conclusion Section. And the only mandatory entry is the Problem Organizer Entry below this section. 


LabelPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 19 templates
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.1IncludeKgreen.png Human Patient (recordTarget) (2008)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA author IHEDYNAMIC
2.16.840.1.113883.10.12.103IncludeKgreen.png CDA dataEntererDYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)DYNAMIC
2.16.840.1.113883.10.12.104IncludeKgreen.png CDA custodianDYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.4IncludeKgreen.png Information Recipient (2008)DYNAMIC
2.16.840.1.113883.2.6.60.6.10.49IncludeKyellow.png CDA legalAuthenticator IHEDYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.3IncludeKyellow.png CDA authenticator IHEDYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.6IncludeKgreen.png Ordering Provider (2008)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.1IncludeKyellow.png CDA Participant Specimen CollectorDYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2008)DYNAMIC
2.16.840.1.113883.10.12.113IncludeKgreen.png CDA componentOfDYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.1ContainmentKyellow.png Clinical Information Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.2ContainmentKyellow.png Intraoperative Observation Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.3ContainmentKyellow.png Macroscopic Observation Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.4ContainmentKyellow.png Microscopic Observation Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.3.10.3.1ContainmentKyellow.png Additional Specified Observation Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.5ContainmentKyellow.png Diagnostic Conclusion Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.6ContainmentKyellow.png Procedure Steps Section (2.0)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.1 (2005‑09‑07)
Example
example for use case #1
<ClinicalDocument xsi:schemaLocation="urn:hl7-org:v3 infrastructure/cda/CDA.xsd">
  <realmCode code="UV"/>  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>  <templateId root="1.3.6.1.4.1.19376.1.8.1.1.1"/>  <id extension="A7102400008_1" root="1.3.6.1.4.1.19376.1.8.9.1"/>  <code code="11526-1" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology Study"/>  <title>Anatomic Pathology Structured Report - Breast Biopsy</title>  <effectiveTime value="20161202090407"/>  <confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25"/>  <languageCode code="en-US"/>  <setId extension="A7102400008" root="1.3.6.1.4.1.19376.1.8.9.1"/>  <versionNumber value="1"/>  <!-- Patient -->
  <recordTarget>
    <patientRole>
      <id extension="0411886319605719371016" root="1.3.6.1.4.1.19376.1.8.9.2"/>      <addr use="HP">
        <streetAddressLine>39 East Street</streetAddressLine>        <postalCode>69499</postalCode>        <city>Appleton</city>        <state>WI</state>        <country>United States</country>      </addr>      <telecom nullFlavor="NASK"/>      <patient>
        <name>
          <prefix>Miss</prefix>          <given>EVE</given>          <family qualifier="BR">ONEWOMAN</family>        </name>        <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>        <birthTime value="19710921"/>      </patient>    </patientRole>  </recordTarget>  <!-- one or more author(s) of the report, with authoring time -->
  <author>
    <templateId root="1.3.6.1.4.1.19376.1.8.1.4.2"/>    <time value="20100104131933-0500"/>    <assignedAuthor>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>      <addr nullFlavor="MSK"/>      <telecom value="tel:+33-602030499"/>      <assignedPerson>
        <name>
          <given>Marcel</given>          <family>Pathologist</family>          <suffix>Ph D</suffix>        </name>      </assignedPerson>      <representedOrganization>
        <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>        <name>CANCER INSTITUTE</name>        <telecom nullFlavor="MSK"/>        <addr nullFlavor="MSK"/>      </representedOrganization>    </assignedAuthor>  </author>  <!-- one or more transcriptionists, with transcription time -->
  <dataEnterer>
    <time value="20100104131720-0500"/>    <assignedEntity>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="A32"/>      <addr nullFlavor="MSK"/>      <telecom nullFlavor="MSK"/>      <assignedPerson>
        <name>
          <given>Adeline</given>          <family>Medsecret</family>        </name>      </assignedPerson>    </assignedEntity>  </dataEnterer>  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Body) APSR2' (dynamic), not used in use case #1 -->
  </informant>  <!-- The unique custodian of this document is the sending pathology lab that will administer it (further updates, deprecation) -->
  <custodian>
    <assignedCustodian>
      <representedCustodianOrganization>
        <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>        <name>CANCER INSTITUTE</name>        <telecom use="PUB" value="0466666666"/>        <addr>
          <streetAddressLine>38 Cramberry Street</streetAddressLine>          <postalCode>69499</postalCode>          <city>Appleton</city>          <state>WI</state>        </addr>      </representedCustodianOrganization>    </assignedCustodian>  </custodian>  <!-- One or more additional intended recipients (other than the ordering physician) -->
  <informationRecipient>
    <templateId root="1.3.6.1.4.1.19376.1.3.3.1.4"/>    <intendedRecipient>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="987"/>      <addr>
        <streetAddressLine>1600 Clifton Road</streetAddressLine>        <city>Atlanta</city>        <state>GA</state>        <postalCode>30333</postalCode>      </addr>      <telecom value="tel:404-639-3535"/>      <informationRecipient>
        <name>
          <family>WOULDLIKETOKNOW</family>          <given>Thomas</given>        </name>      </informationRecipient>    </intendedRecipient>  </informationRecipient>  <!-- The unique legal authenticator: The person assuming the final responsibility of the report and signing it -->
  <legalAuthenticator>
    <time value="20100104152503-0500"/>    <signatureCode code="S"/>    <assignedEntity>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>      <assignedPerson>
        <name>
          <given>Marcel</given>          <family>Pathologist</family>        </name>      </assignedPerson>    </assignedEntity>  </legalAuthenticator>  <!-- Zero or more additional content validator(s): pathologists having validated some part of the report -->
  <authenticator>
    <templateId root="1.3.6.1.4.1.19376.1.8.1.4.3"/>    <time value="20100104142503-0500"/>    <signatureCode code="S"/>    <assignedEntity>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567898"/>      <addr nullFlavor="MSK"/>      <telecom nullFlavor="MSK"/>      <assignedPerson>
        <name>
          <given>Jonas</given>          <family>Jones</family>          <prefix>MD</prefix>        </name>      </assignedPerson>    </assignedEntity>  </authenticator>  <!-- The ordering physician -->
  <participant typeCode="REF">
    <templateId root="1.3.6.1.4.1.19376.1.3.3.1.6"/>    <time>
      <hl7:high value="20091231"/>    </time>    <associatedEntity classCode="PROV">
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567892"/>      <addr nullFlavor="NASK"/>      <telecom value="tel:0147150000" use="EC"/>      <associatedPerson>
        <name>
          <prefix>Doctor</prefix>          <given>Eva</given>          <family>Surgeon</family>          <suffix>Ph D</suffix>        </name>      </associatedPerson>    </associatedEntity>  </participant>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.1 'CDA participant specimen collector' (dynamic) 0..* R, not used in use case #1 -->
  <!-- Identification of the order, extension is Order-ID -->
  <inFulfillmentOf>
    <order>
      <id root="1.3.6.1.4.1.19376.1.8.9.8" extension="12345"/>    </order>  </inFulfillmentOf>  <!-- Documented act(s): The pathology examination procedure, extension is Accession number -->
  <documentationOf>
    <serviceEvent>
      <id root="1.3.6.1.4.1.19376.1.8.9.9" extension="A7102400008"/>      <code code="PATREPE" displayName="pathology report entry task" codeSystem="2.16.840.1.113883.5.4" codeSystemName="HL7 ActCode/"/>      <effectiveTime>
        <!-- Start: Date&time of reception of this order and the attached specimens -->
        <low value="200912300922-0500"/>        <!-- End -->
        <high value="201001041605-0500"/>      </effectiveTime>      <!-- Status of the document: complete(final) vs active(preliminary) -->
      <statusCode code="complete"/>      <!-- Performing laboratory -->
      <performer typeCode="PRF">
        <templateId root="1.3.6.1.4.1.19376.1.3.3.1.7"/>        <time>
          <high value="201001041605-0500"/>        </time>        <assignedEntity>
          <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>          <representedOrganization>
            <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>            <name>CANCER INSTITUTE</name>            <telecom nullFlavor="MSK"/>            <addr nullFlavor="MSK"/>          </representedOrganization>        </assignedEntity>      </performer>    </serviceEvent>  </documentationOf>  <!-- include template 1.3.6.1.4.1.19376.1.3.1.9999.10.9.16 'RelatedDocument Parent Document' (dynamic) 0..1 R, not used in use case #1 -->
  <!-- Patient encounter: The patient stay in the hospital where the surgery was performed -->
  <componentOf>
    <encompassingEncounter>
      <id root="1.3.6.1.4.1.19376.1.8.9.7" extension="234567890"/>      <code code="ACUTE" displayName="inpatient acute"/>      <effectiveTime>
        <high value="2201001040735-0500"/>      </effectiveTime>      <location typeCode="LOC">
        <healthCareFacility classCode="SDLOC">
          <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="11223344"/>          <serviceProviderOrganization classCode="ORG" determinerCode="INSTANCE">
            <name>Surgery theater</name>            <asOrganizationPartOf>
              <wholeOrganization>
                <name>CANCER INSTITUTE</name>              </wholeOrganization>            </asOrganizationPartOf>          </serviceProviderOrganization>        </healthCareFacility>      </location>    </encompassingEncounter>  </componentOf>  <!-- Structured body -->
  <component typeCode="COMP" contextConductionInd="true">
    <structuredBody classCode="DOCBODY" moodCode="EVN">
      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.1 'Clinical Information Section' (dynamic) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.2 'Intraoperative Observation Section' (dynamic) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.3 'Macroscopic Observation Section' (dynamic) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.4 'Microscopic Observation Section' (dynamic) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.3.10.3.1 'Additionally Specified Observation Section' (dynamic) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.5 'Diagnostic Conclusion Section' (dynamic) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.6 'Procedure Steps Section' (dynamic) -->
      </component>    </structuredBody>  </component></ClinicalDocument>
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treetree.png@classCode
cs0 … 1FDOCCLIN
Treetree.png@moodCode
cs0 … 1FEVN
Treetree.pnghl7:realmCode
CS CWE1 … 1MThis element SHALL be present and is valued from the RealmOfUse [2.16.840.1.113883.1.11.11050] subset, within the VocabularyDomainQualifier value set. In the international context of this profile used as it is without any further extension, the realm code SHALL be <realmCode code="UV"/> (universal).

Whenever a national extension has been defined and is used, the realm code SHALL identify this national extension.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treetree.pnghl7:typeId
II1 … 1MThis element is a technology-neutral explicit reference to the standard CDA R2. It SHALL be present and valued as follows:
ClinicalDocument/typeId@root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models);
ClinicalDocument.typeId@extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description).
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.1.3
Treeblank.pngTreetree.png@extension
st1 … 1FPOCD_HD000040
Treetree.pnghl7:templateId
II1 … 1MThis element is identifying the set of constraints applied to the CDA R2 standard by this IHE specification of a AP report. The following templateId SHALL be present and valued as follows to indicate compliance with the APSR 2.0 content module specification.
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.1.1
Treetree.pnghl7:id
II1 … 1MClinicalDocument/Id SHALL be present. It represents the unique instance identifier of the clinical document. The combination of the root and extension attributes SHALL provide a globally unique identifier, in accordance with CDA R2, without further constraints.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@root
uid1 … 1RHere the OID for PAT exemplary instances, in practice the OID of the LIS
Treeblank.pngTreetree.png@extension
st1 … 1RHere a hypothetical document ID, most often derived from the accession number
 ConstraintA report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report.
The unique id of the current revision of the report is carried by the id element, and is composed of 
  • id@root, which SHALL be an OID,
  • and optionally id@extension, which can be any string so that the concatenation of the two attributes root and extension provide a globally unique id, which identifies this release of the report. 
 Example
Report ID from use case #1
<id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_1" assigningAuthorityName="IHE PaLM Technical Committee"/>
Treetree.pnghl7:code
CE CNE1 … 1MClinicalDocument/code SHALL be present. The document type of this content module is always
<code code="11526-1"
codeSystem="2.16.840.1.113883.6.1"
displayName="Pathology Study"
codeSystemName="LOINC"/>


PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@code
CONF1 … 1F11526-1
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1FPathology Study
Treetree.pnghl7:title
ST1 … 1MThe APSR <title> SHALL be present. It is the local translation of the code@displayName.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 CONF
element content shall be "Anatomic Pathology Structured Report"
 Example
Report title from use case #1
<title>ANATOMIC PATHOLOGY REPORT - BREAST BIOPSY</title>
Treetree.pnghl7:effectiveTime
TS1 … 1MClinicalDocument/effectiveTime SHALL be present. It contains the creation date & time of the laboratory report as an electronic document. In case this is a new revision replacing a previous version (identified in parentDocument), this is the date & time of the new revision.
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treetree.pnghl7:confidentialityCode
CE1 … 1MClinicalDocument/confidentialityCode SHALL be present in accordance with the HL7 CDA R2 standard.
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)
Treetree.pnghl7:language​Code
CS1 … 1MClinicalDocument/languageCode SHALL be present in accordance with the HL7 CDA R2 standard.
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
Treetree.pnghl7:setId
II1 … 1MClinicalDocument/setId SHALL be present to enable further updates of the clinical document. It is an identifier that is common across all revisions of this laboratory report.
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@root
uid1 … 1R
Treeblank.pngTreetree.png@extension
st1 … 1R
 ConstraintA report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report.
The setId element provides a globally unique identifier that is common across all successive revisions of the report. This identifier is similarly composed of setId@root, which SHALL be an OID, and optionally setId@extension. 
 Example
Report set ID from use case #1
<id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008" assigningAuthorityName="IHE PaLM Technical Committee"/>
Treetree.pnghl7:versionNumber
INT0 … 1RClinicalDocument/versionNumber MAY be present. As requested by the CDA standard, it is an integer value used as versioning.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@value
int1 … 1R
 ConstraintA report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report.
The version number of the current revision of the report is a positive integer (1, 2 …) provided in the versionNumber element.
 Example
Report version number for use case #1
<versionNumber value="1"/>
Included1 … 1M from 1.3.6.1.4.1.19376.1.3.3.1.1 Human Patient (recordTarget) (DYNAMIC)
Patient.
The anatomic pathology report is related to one single patient. 
  • A patient SHALL be identified with at least one unique id.  
  • The patient address and telecom SHALL be provided (or null flavored).  
  • The patient identity SHALL provide at least the patient full name, sex and date/time of birth. 
Treetree.pnghl7:recordTarget
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
cs0 … 1FRCT
Treeblank.pngTreetree.png@context​Control​Code
cs0 … 1FOP
Treeblank.pngTreetree.pnghl7:patientRole
1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPAT
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … *All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:patient
1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:administrative​Gender​Code
CE1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 AdministrativeGender (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:birthTime
TS1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Included1 … *M from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (DYNAMIC)
The Author Content Module represents an author of the report. This element is repeatable. The sub-element  author/time  carries the date/time of the authoring action. 

At least one ClinicalDocument/author SHALL be present with a time in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. The author/time element carries the date&time the AP report was produced. The AP report can be authored by a software system or by a person or by both.

Source: PaLM Suppl.APSR 2.0‑3: 6.3.6.2
Treetree.pnghl7:author
1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.png@typeCode
cs1 … 1FAUT
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor></author>
Treeblank.pngTreetree.pnghl7:templateId
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
Treeblank.pngTreetree.pnghl7:time
TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:assignedAuthor
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1
The author is either an assigned person or an authoring device.
Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC)
The name(s) SHALL be given.
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
0 … 1CPaLM 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
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 Example
represented organization for author as a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name></representedOrganization>
Included0 … 1 from 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC)
The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … 1PaLM 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
Included0 … * from 2.16.840.1.113883.10.12.103 CDA dataEnterer (DYNAMIC)
Transcriptionist
Treetree.pnghl7:dataEnterer
0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
0 … 1FENT
Treeblank.pngTreetree.png@context​Control​Code
0 … 1FOP
Treeblank.pngTreetree.pnghl7:time
TS0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.pnghl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treetree.pnghl7:informant
0 … *Zero or more informant MAY be mentioned in the header of the report. An informant is either an  assignedEntity  (a professional participating to the healthcare process, and who was assigned a defined role in that process) or a  relatedEntity  (a person who knows the patient and has provided relevant information concerning the patient). Hence the condition is either  assignedEntity  is present or  relatedEntity  is present. These two elements are defined in the content module “Informant”.

Source: PaLM Suppl. APSR 2.0-3: 6.3.6.5

Contains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (DYNAMIC)		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Included1 … 1M from 2.16.840.1.113883.10.12.104 CDA custodian (DYNAMIC)
ClinicalDocument/custodian SHALL be present with an id in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. It represents the organization that is in charge of maintaining the AP report.
Treetree.pnghl7:custodian
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
0 … 1FCST
Treeblank.pngTreetree.pnghl7:assignedCustodian
1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Custodian​Organization
1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Included0 … * from 1.3.6.1.4.1.19376.1.3.3.1.4 Information Recipient (DYNAMIC)
The Intended Recipient Content Module represents a healthcare provider,  other than the ordering physician, expecting to receive a copy of the report. This repeatable element informationRecipient of the CDA header is used to list the intended recipients who were known at the time the report was created and issued. 


Source: PaLM TF-3: 6.3.2.14
Treetree.pnghl7:information​Recipient
0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19366 x_InformationRecipient (DYNAMIC)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@root
1 … 1F1.3.6.1.4.1.19376.1.3.3.1.4
Treeblank.pngTreetree.pnghl7:intended​Recipient
1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1R
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.16772 x_InformationRecipientRole (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:information​Recipient
0 … 1Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:received​Organization
0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Included1 … 1M from 2.16.840.1.113883.2.6.60.6.10.49 CDA legalAuthenticator IHE (DYNAMIC)
The Legal authenticator Content Module describes a pathologist having verified the content of the report, using the element legalAuthenticator.

The report SHALL have one legal Authenticator


Source: PaLM TF-3: 6.3.2.15

Treetree.pnghl7:legalAuthenticator
1 … 1MPaLM TF‑3: 6.3.2.15 Legal authenticator
Treeblank.pngTreetree.png@typeCode
cs0 … 1FLA
Treeblank.pngTreetree.png@context​Control​Code
cs0 … 1FOP
Treeblank.pngTreetree.pnghl7:time
TS1 … 1RPaLM TF‑3: 6.3.2.15 Legal authenticator
Treeblank.pngTreetree.pnghl7:signatureCode
CS1 … 1RPaLM TF‑3: 6.3.2.15 Legal authenticator
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)
Treeblank.pngTreetree.pnghl7:assignedEntity
1 … 1RContains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)PaLM TF‑3: 6.3.2.15 Legal authenticator
Included0 … * from 1.3.6.1.4.1.19376.1.8.1.4.3 CDA authenticator IHE (DYNAMIC)

The Content validator Content Module describes a pathologist having verified the content of the report, using the element authenticator. This element authenticator is used when the pathologist having verified the content of the report is distinct from the pathologist assuming the legal responsibility for this report, described in the legalAuthenticator element.

The report MAY have zero or more Content Validators.


Source: PaLM Suppl. APSR 2.0-3: 6.3.6.3
Treetree.pnghl7:authenticator
0 … *PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator
Treeblank.pngTreetree.png@typeCode
cs1 … 1FAUTHEN
Treeblank.pngTreetree.pnghl7:templateId
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.3
Treeblank.pngTreetree.pnghl7:time
TS1 … 1RTime of validationPaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator
Treeblank.pngTreetree.pnghl7:assignedEntity
0 … 1CAssignedPerson SHALL be given with name, representedOrganization MAY be given.
Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)		PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator
Included0 … 1R from 1.3.6.1.4.1.19376.1.3.3.1.6 Ordering Provider (DYNAMIC)
The Ordering Provider Content Module represents the physician who has submitted the specimen examination order to the anatomic pathology laboratory. As specified in PaLM TF-3, this physician is represented in the CDA header as a participant element with the typeCode attribute valued “REF”. The sub-element participant/time carries the date/time of issuance of the 
           order.

Source: PaLM TF-3: 6.3.2.17
Treetree.pnghl7:participant
0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
1 … 1FREF
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@root
1 … 1F1.3.6.1.4.1.19376.1.3.3.1.6
Treeblank.pngTreetree.pnghl7:time
IVL_TS0 … 1RThis element represents the date and time the order was placed. Time MAY be present.PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.pnghl7:associated​Entity
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@classCode
1 … 1FPROV
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1RUnique identifier of this person (referral ordering physician) in the affinity domain SHALL be present.PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … 1RThe address of this person (referral ordering physician) SHALL be present.PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL.AT1 … *RThe telecom of this person (referral ordering physician) SHALL be present.PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 Schematron assertroleKred.png error 
 testhl7:assigned​Person/hl7:name 
 MessageAn <assignedPerson> SHALL be present, the <name> sub-element SHALL be present. 
Treeblank.pngTreeblank.pngTreetree.pnghl7:associated​Person
1 … 1RContains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:scoping​Organization
0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Included0 … *R from 1.3.6.1.4.1.19376.1.8.1.4.1 CDA Participant Specimen Collector (DYNAMIC)
The Specimen Collector Content Module is only used in case a specimen provided as input to the AP act documented in this report, was collected by a different party than the ordering physician. In that case, this specimen collector is represented in the CDA header as a participant element with the typeCode attribute valued “DIST” and the sub-element participant/time carries the time period of the specimen collection.

Source: PAT TF-3: 6.2.6.1


Treetree.pnghl7:participant
0 … *RThe Specimen Collector Content Module is only used in case a specimen provided as input to the AP act documented in this report, was collected by a different party than the ordering physician. In that case, this specimen collector is represented in the CDA header as a participant element with the typeCode attribute valued “DIST” and the sub-element participant/time carries the time period of the specimen collection.
PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreetree.png@typeCode
cs1 … 1FDIST
Treeblank.pngTreetree.pnghl7:templateID
II1 … 1MPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.1
Treeblank.pngTreetree.pnghl7:time
IVL_TS1 … 1MSpecimen collection time

The specimen collection time is an interval, which may be reduced to a point in time (see usage of data type IVL_TS).
PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreetree.pnghl7:associated​Entity
0 … 1RAt least one of the two elements associatedPerson and scopingOrganization must be present. Both may be present. 

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FPROV
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … *RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL.AT1 … *RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreeblank.pngTreetree.pnghl7:associated​Person
0 … *CPerson who collected the specimen.
Only full name(s) SHALL be given.
Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)		PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreeblank.pngTreetree.pnghl7:scoping​Organization
0 … 1COrganization taking care for specimen collection.
Identifiers, name, telecom, and address SHOULD be given.
Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)		PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treetree.pnghl7:inFulfillmentOf
0 … 1RThe inFulfillmentOf/order element MAY be present. It represents the Placer Order or the Placer Group that was fulfilled, the Id of which is carried by inFulfillmentOf/order/id.
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
cs1 … 1FFLFS
Treeblank.pngTreetree.pnghl7:order
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FACT
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 … 1FRQO
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *RPlacer order group ID or Placer order ID
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treetree.pnghl7:documentationOf
1 … 1MDocumented act.PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
cs1 … 1FDOC
Treeblank.pngTreetree.pnghl7:serviceEvent
1 … 1MThe AP report is documenting a service (documentationOf/serviceEvent) performed by a surgical pathology laboratory. The Laboratory Performer Content Module represents this laboratory, and is fully described in the sub-element documentationOf/serviceEvent/performer.
In case more than one laboratory contributed to a service, only the primary laboratory is in the CDA header, attached to the serviceEvent element, and the other (secondary) laboratories are described only in the sections of the report that they contributed to, in the body of the report.


Source: PaLM TF3: 6.3.2.19

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1R
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 … 1R
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *MID of the Act, i.e. Accession numberPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE CWE0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 CONF
@code shall be "PATREPE"
@codeSystem shall be "2.16.840.1.113883.5.4"
@codeSystemName shall be "HL7 ActCode"
@displayName shall be "pathology report entry task"
or
@code shall be "371528001"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SCT"
@displayName shall be "Pathology report (record artifact)"
Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1RUse of sub element documentationOf/serviceEvent/effectiveTime to document the time boundaries of events in the document is appropriate.
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pngihe-lab:statusCode
CS CNE0 … 1

This APSR Content Module can express both final and non-final reports. To distinguish between the two, the statusCode element has been added to the documentationOf/serviceEvent element. A non-final report is a report documenting a serviceEvent, which is in the status "active". This sub-element serviceEvent/statusCode is optional. When it is not present the serviceEvent is assumed to be in the status "completed".
The statusCode below documentationOf/serviceEvent is an extension to the CDA R2 standard, added by PaLM TF-3 to distinguish a preliminary report (statusCode@code="active") from a final report (statusCode@code="completed"). 
The statusCode sub element is  further described in section A.3 of PaLM TF-3. This sub-element is required. When it is not there, the documented Act is assumed to be completed and the report is assumed to be a final report.


This extension to the standard is protected by a dedicated namespace associated in the ClinicalDocument element to the prefix lab:

<Clinical Document  xmlns:lab="urn:oid:1.3.6.1.4.1.19376.1.3.2" … > 

Source: PaLM TF3: 6.3.2.19

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 ConstraintThe statusCode@code="completed" is only applicable, if ALL content modules of the Clinical Document have the statusCode@code="completed", too, or have the statusCode@code="aborted".
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.4 ActStatusActiveCompleted (DYNAMIC)
 Schematron assertroleKred.png error 
 testhl7:serviceEvent/ihe-lab:statusCode[@code='completed'] 
 MessageStatus code of all Content Modules SHALL be "complete" or "aborted" 
Treeblank.pngTreeblank.pngTreetree.pnghl7:performer
0 … *RContains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treetree.pnghl7:relatedDocument
0 … 1R

ClinicalDocument/relatedDocument/parentDocument

This element SHALL be present in case of an update replacement of a previous report. In this case relatedDocument@typeCode attribute SHALL be valued "RPLC", the new report replacing the parent one.

Note 1: A non-final laboratory report published in an XDS infrastructure will likely be replaced afterwards by the final report. When this event occurs, the Content Creator Actor SHALL apply the following rules:

  • ClinicalDocument/setId SHALL have the same value in the new report as in the replaced report.
  • ClinicalDocument/versionNumber SHALL be incremented in the replacing report (i.e., the final one).
  • ClinicalDocument/relatedDocument@typeCode attribute SHALL be valued ”RPLC”
  • ClinicalDocument/relatedDocument/parentDocument/id in the new report SHALL be equal to ClinicalDocument/ id of the replaced document.

The Document Source Actor SHALL apply the following rules on XDSDocumentEntry metadata:

  • The final report SHALL be associated with the previously published one, using RPLC relationship and the previous report SHALL be “Deprecated” as described in ITI TF-2:4.1.6.1.

Note 2: A non-final report can also be replaced by a more recent, albeit still non-final report. The rules above also apply in this case.

Note 3: A final report can also be replaced by a corrective final report. The rules above also apply in this case.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
cs1 … 1FRPLC
 relatedDocument@typeCode attribute SHALL be valued "RPLC"
Treeblank.pngTreetree.pnghl7:parentDocument
ANY1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1MSHALL be equal to ClinicalDocument/ id of the replaced document.
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:setId
II1 … 1MSHALL have the same value in the new report as in the replaced report.
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:versionNumber
INT0 … 1RSHALL have the same value as in the replaced report (when provided there).
PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Included0 … 1R from 2.16.840.1.113883.10.12.113 CDA componentOf (DYNAMIC)
The ClinicalDocument/componentOf/encompassingEncounter element MAY be present.

It describes the encounter during which the reported AP observations were ordered. When present the encounter SHALL:

  • be identified with an id element: encompassingEncounter/id
  • The encounter SHALL have an effective time that represents the time interval (possibly still running, e.g., an inpatient current stay) of the encounter or a point in time at which the encounter took place (e.g., an outpatient consultation): encompassingEncounter/ effectiveTime

The encounter MAY provide any number of encounter participants (encompassingEncounter/encounterParticipant/assignedEntity). When present, encounter participants SHALL be in accordance with the HL7 CDA R2 standard with a time and further constrained by this specification to require the presence of name, addr and telecom. Additionally, the encounter participant SHALL have a typeCode with one the values selected from the x_EncounterParticipant domain: The encounter MAY precise the patient location during this encounter. This is the healthcare facility in which the patient was located when the reported AP observations were ordered: encompassingEncounter/location/healthCareFacility. This healthcare facility can be represented as a physical place (e.g., room, floor, building, office) or as an organization (e.g., service, department, team) or both: healthCareFacility/location, healthCareFacility/serviceProviderOrganization.

Treetree.pnghl7:componentOf
0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
0 … 1FCOMP
Treeblank.pngTreetree.pnghl7:encompassing​Encounter
1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FENC
Treeblank.pngTreeblank.pngTreetree.png@moodCode
0 … 1FEVN
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:discharge​Disposition​Code
CE0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 CONF
shall be drawn from concept domain "EncounterDischargeDisposition"
Treeblank.pngTreeblank.pngTreetree.pnghl7:responsible​Party
0 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
0 … 1FRESP
Treeblank.pngTreeblank.pngTreetree.pnghl7:encounterParticipant
0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:time
IVL_TS0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.pnghl7:location
0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
0 … 1FLOC
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:health​Care​Facility
1 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FSDLOC
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:location
0 … 1Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:service​Provider​Organization
0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treetree.pnghl7:component
1 … 1RBody of the CDA Clinical documentPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl1 … 1Ftrue
Treeblank.pngTreetree.pnghl7:structuredBody
1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FDOCBODY
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 … 1FEVN
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1RThe Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, clinical laboratory data, specimen(s) description, collection procedure, reason for anatomic pathology procedure.
Contains 1.3.6.1.4.1.19376.1.8.1.2.1 Clinical Information Section (DYNAMIC)		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
bl1 … 1Ftrue
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1R

The Intraoperative Observation section contains an intraoperative diagnosis for each specimen examined, the specimen identification and description, intraoperative observation procedure description (frozen section, gross examination, intraoperative cytology) and derived specimen dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, and electron microscopy).


Contains 1.3.6.1.4.1.19376.1.8.1.2.2 Intraoperative Observation Section (DYNAMIC)		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
bl1 … 1Ftrue
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1RThe Macroscopic Observation section contains the description of the specimen received or obtained by the laboratory (specimen type and state), the gross observation, links to gross images, if taken, processing information and tissue disposition (representative sampling and tissue submitted for additional studies or sent to biorepository.
Contains 1.3.6.1.4.1.19376.1.8.1.2.3 Macroscopic Observation Section (DYNAMIC)		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
bl1 … 1Ftrue
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1R

The Microscopic Observation section contains optionally the histopathologic findings of the case and many laboratories use this section to record the results of histochemical and immunohistochemical stains.


Contains 1.3.6.1.4.1.19376.1.8.1.2.4 Microscopic Observation Section (DYNAMIC)		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
bl1 … 1Ftrue
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1R

The Additional Specific Observation section includes additional pathologic finding(s) and the results of ancillary study(ies) with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken. 


Contains 1.3.6.1.4.1.19376.1.3.10.3.1 Additional Specified Observation Section (DYNAMIC)		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
bl1 … 1Ftrue
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
1 … 1M

The 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.


Contains 1.3.6.1.4.1.19376.1.8.1.2.5 Diagnostic Conclusion Section (DYNAMIC)		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.png where [not(@nullFlavor)]
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
bl1 … 1Ftrue
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
0 … 1R

The Procedure steps section contains the description of tissue dissection: representative specimens and derived specimens dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, electron microscopy, etc.) or biorepository.


Contains 1.3.6.1.4.1.19376.1.8.1.2.6 Procedure Steps Section (DYNAMIC)		PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
bl1 … 1Ftrue
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