| Item | DT | Card | Conf | Description | Label |
|---|
| | 0 … * | R | Problem organizer groups the battery of observations performed to investigate on a single problem identified on a specimen or a group of specimens. | PaLM…izer |
 | @classCode
|
| cs | 1 … 1 | F | BATTERY |
| @moodCode
|
| cs | 1 … 1 | F | EVN |
| hl7:templateId
|
| II | 1 … 1 | M | | PaLM…izer |
 | | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.8.1.3.6 |
| hl7:id
|
| II | 0 … * | R | | PaLM…izer |
| hl7:code
|
| CD CNE | 0 … 1 | R | Problem
| PaLM…izer |
| | @code
|
| CONF | 1 … 1 | F | 75326-9 |
| | @codeSystem
|
| 1 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) |
| | @codeSystemName
|
| 1 … 1 | F | LOINC |
| | @displayName
|
| 1 … 1 | F | Problem |
| hl7:component
|
| | 0 … 1 | R | Coding of the Problem reported | PaLM…izer |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | hl7:observation
|
| CD CWE | 0 … 1 | R | | PaLM…izer |
| CD CWE | 1 … 1 | R | | PaLM…izer |
| CONF | 1 … 1 | F | 75326-9 |
| 1 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) |
| 1 … 1 | F | LOINC |
| 1 … 1 | F | Problem |
| CR | 0 … * | R | Optional qualifier for separate problems with identical problem type in one specimen, e.g. a urothelial bladder cancer Invasive cancer) and a prostate cancer (invasive cancer) in one cystoprostatectomy specimen. The anatomic structure is able to differentiate.
| PaLM…izer |
| | Example | Problem in urinary bladder in cystoprostatectomy specimen <qualifier>
<name code="116677004" codeSystem="2.16.840.1.113883.6.96" displayName="Associated topography (attribute)" codeSystemName="SNOMED-CT"/> <value code="302512001" codeSystem="2.16.840.1.113883.6.96" displayName=" Entire urinary bladder (body structure)" codeSystemName="SNOMED-CT"/></qualifier> |
| CV | 0 … 1 | R | | PaLM…izer |
| cs | 1 … 1 | F | 116677004 |
| oid | 1 … 1 | F | 2.16.840.1.113883.6.96 |
| st | 1 … 1 | F | Associated topography (attribute) |
| CD CWE | 0 … * | R | | PaLM…izer |
| CONF | 1 … 1 | F | << 91723000 |
| 1 … 1 | F | 2.16.840.1.113883.6.96 (SNOMED Clinical Terms) |
| 1 … 1 | F | SNOMED-CT |
| 1 … 1 | F | all values from Anatomical structure |
| CE CWE | 0 … 1 | R | Code of the problem reported | PaLM…izer |
| | CONF | | @code shall be "any_code" | | @codeSystem shall be "2.16.840.1.113883.6.3" | | @codeSystemName shall be "any_code" | | @displayName shall be "ICD-10" | | or | | The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.7 Problem Type (DYNAMIC) |
|
| hl7:statusCode
|
| CS CNE | 1 … 1 | M | | PaLM…izer |
| | Constraint | The status of the organizer is completed if the battery of observations for this problem has been performed. It is aborted in case some of the intended observations could not be achieve and have been aborted, and appear as such below the organizer.
|
| | CONF | | The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 ActStatusAbortedCompleted (DYNAMIC) |
|
| hl7:effectiveTime
|
| IVL_TS | 1 … 1 | M | Organizer time.
The period of time (possibly reduced to a point in time) during which the information was collected and assembled.
| PaLM…izer |
| hl7:author
|
| | 0 … * | C | Author
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2
Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (DYNAMIC) | PaLM…izer |
| | Constraint | The author SHALL be present if it is different from the main author of the report. For instance the author could be the ordering physician contributing to the Clinical Information section, inside a report authored by the pathologist.
|
| hl7:informant
|
| | 0 … * | R | Informant
The informant is an actor (person and organization) who provided some of the clinical information carried by this organizer.
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…izer |
| hl7:participant
|
| | 0 … * | R | Transcriptionist, Device, Responsible, Validator
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.6
Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry APSR (Body) (DYNAMIC) | PaLM…izer |
| | Constraint | participationType "ENT", "DEV", "RESP", "AUTHEN"
|
| hl7:performer
|
| | 0 … 1 | C | Performing lab.
The performing laboratory is present at this level only if this particular problem on this particular specimen was investigated by a (subcontractor) distinct laboratory from the one issuing the consolidated report
Source: PaLM TF-3: 6.3.2.20
Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC) | PaLM…izer |
| Included | 0 … * | R | from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC)
Specimen identification outside an AP observation for differentiating or restituting the problem type
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.9
|
| hl7:specimen
|
| | 0 … * | 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 |
| | 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 |
| hl7:component
|
| | 0 … * | R | Embedded image
This organizer may carry an image focusing on the problem, either directly embedded or encapsulated within a region of interest.
Contains 1.3.6.1.4.1.19376.1.8.1.4.10 Embedded Image IHE (DYNAMIC) | PaLM…izer |
| | @typeCode
|
| cs | 0 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | Constraint | [@classCode="ROIOVL" and moodCode="EVN"] |
| | hl7:sequenceNumber
|
| INT | 0 … 1 | | | PaLM…izer |
| | hl7:seperatableInd
|
| BL | 0 … 1 | | | PaLM…izer |
| hl7:component
|
| | 0 … * | R | Region of interest
This organizer may carry an image focusing on the problem, either directly embedded or encapsulated within a region of interest.
In the latter case by an entryRelationship @typeCode="SUBJ"
Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (DYNAMIC) | PaLM…izer |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | Constraint | [@classCode="ROIOVL" and moodCode="EVN"] |
| | hl7:sequenceNumber
|
| INT | 0 … 1 | | | PaLM…izer |
| | hl7:seperatableInd
|
| BL | 0 … 1 | | | PaLM…izer |
| hl7:component
|
| | 0 … * | R | General comment on this particular problem
Source: PCC TF-2: 6.3.4.6
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 Annotation Comment (2008‑08‑08) | PaLM…izer |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | hl7:sequenceNumber
|
| INT | 0 … 1 | | | PaLM…izer |
| | hl7:seperatableInd
|
| BL | 0 … 1 | | | PaLM…izer |
| hl7:component
|
| | 0 … * | R | Any kind of AP observation, for complex observation templates, e.g. for TNM, ICD-O-3, or Assessment scales can be used.
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.7
Contains 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (DYNAMIC) | PaLM…izer |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | hl7:sequenceNumber
|
| INT | 0 … 1 | | | PaLM…izer |
| | hl7:seperatableInd
|
| BL | 0 … 1 | | | PaLM…izer |
| hl7:component
|
| | 0 … * | C | Laboratory observation
Contains 1.3.6.1.4.1.19376.1.3.1.6 Laboratory Observation (DYNAMIC) | PaLM…izer |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | hl7:sequenceNumber
|
| INT | 0 … 1 | | | PaLM…izer |
| | hl7:seperatableInd
|
| BL | 0 … 1 | | | PaLM…izer |
Draft
