1.3.6.1.4.1.19376.1.8.1.2.2

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Template IntraoperativeObservationSection

Description

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).

Actual version

Id	1.3.6.1.4.1.19376.1.8.1.2.2	Effective Date	valid from 2014‑05‑13 19:29:16
Status	Draft	Version Label	2.0
Name	IntraoperativeObservationSection	Display Name	Intraoperative Observation Section
Description 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).
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.2
Label	PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
Classification	CDA Section Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 1 template, Uses 2 templates Used by as Name Version 1.3.6.1.4.1.19376.1.8.1.1.1 Containment Anatomic Pathology Structured Report Content Module (2.0) 2014‑05‑13 11:57:57 Uses as Name Version 1.3.6.1.4.1.19376.1.8.1.4.2 Include CDA author IHE 2016‑06‑21 14:02:11 1.3.6.1.4.1.19376.1.8.1.3.6 Containment Problem Organizer (2.0) 2015‑08‑13 10:24:55
Relationship	Specialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example	generated example <section classCode="DOCSECT" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.8.1.2.2"/>  <code code="83321-0" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report intraoperative observation in Specimen Document"/>  <title>INTRAOPERATIVE OBSERVATION SECTION</title>  <text/>  <languageCode/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->   <entry typeCode="COMP" contextConductionInd="true">     <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' Problem Organizer (2015-08-13T10:24:55) -->   </entry></section>
Item DT Card Conf Description Label hl7:section 0 … 1 R PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section @classCode cs 1 … 1 F DOCSECT @moodCode cs 1 … 1 F EVN   Constraint 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 observed. These entries provide the machine-readable data corresponding to the narrative block. This section does not contain any subsection. This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document. hl7:templateId II 1 … 1 R PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.2.2 hl7:code CE 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section @code CONF 1 … 1 F 83321-0 @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 Pathology report intraoperative observation in Specimen Document hl7:title ST 1 … 1 R PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section   CONF element content shall be "INTRAOPERATIVE OBSERVATION SECTION" hl7:text SD.TEXT 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section   Example Intraoperative observation <text>Frozen section diagnosis of infiltrating duct carcinoma, left breast</text> hl7:language​Code CS 0 … 1 PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (2014‑03‑26) Included 0 … * C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11) Author Source: PaLM Suppl. APSR 2.0-3:  6.2.6.2 hl7:author 0 … * C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @typeCode cs 1 … 1 F AUT   Example author is a person <author typeCode="AUT" contextControlCode="OP">   <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">     <!-- ... -->   </assignedAuthor></author> hl7:templateId 1 … 1 M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.4.2 hl7:time TS 1 … 1 M The 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 hl7:assignedAuthor 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F ASSIGNED hl7:id II 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Choice 1 … 1 The author is either an assigned person or an authoring device. Elements to choose from: hl7:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Included 0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07) The name(s) SHALL be given. @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:softwareName SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:represented​Organization 0 … 1 PaLM 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> Included 0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07) The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given. @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:asOrganizationPartOf 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F PART hl7:id II 0 … * R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.111 (Role Code) hl7:statusCode CS 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC) hl7:effectiveTime IVL_TS 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:wholeOrganization 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:entry 0 … * R Source: PAT TF-3:6.2.6.8 Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (2015‑08‑13 10:24:55) PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true

List of all versions of this template

• 2014-05-13 19:29:16 (Under develeopment)