1.3.6.1.4.1.19376.1.3.10.9.43/static-2016-10-11T102617

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Id1.3.6.1.4.1.19376.1.3.10.9.43Effective Date valid from 2016‑10‑11 10:26:17
StatusKyellow.png DraftVersion Label2.0
NameAssessmentScoringItemAPSR2.0Display NameAssessment Scoring Item APSR 2.0
Description
Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF)

Supportive Observation entry template for describing the granular Items for a scoring system, e.g.Elston-Ellis-Score or Gleason Score
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.43
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 3 templates, Uses 5 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.3.10.9.42ContainmentKyellow.png Assessment Scoring System APSR 2.0 (2.0)2016‑10‑10 11:33:36
1.3.6.1.4.1.19376.1.3.10.4.4Link.pngKyellow.png Assessment Scales Observation for Scoring Systems APSR2 (2.0)2016‑10‑06 13:12:00
1.3.6.1.4.1.19376.1.3.10.4.3Link.pngKyellow.png ICD-O-3 Typing and Grading Observation (2.0)2015‑11‑29 17:03:18
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA author IHEDYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.7ContainmentKyellow.png Additional participant in an entry APSR (Body)DYNAMIC
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen IdentifiedDYNAMIC
RelationshipSpecialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 (2014‑05‑14 17:09:54)
Example
example for use case #1: ER-Allred Percentage Score Item
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.9.43"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="444644009" displayName="Number fraction of estrogen receptors in neoplasm using immune stain (observable entity)" codeSystem="2.16.840.1.113883.6.96"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20170224122203"/>  </effectiveTime>  <value xsi:type="PQ" value="85" unit="%"/>  <interpretationCode code="A" displayName="abnormal" codeSystem="2.16.840.1.113883.5.83"/>  <referenceRange typeCode="REVF">
    <observationRange classCode="OBS" moodCode="EVN.CRT">
      <code code="" codeSystem="2.16.840.1.113883.5.4" displayName=""/>      <text/>      <effectiveTime value="20170224122203"/>      <value/>      <interpretation code="A" displayName="abnormal" codeSystem="2.16.840.1.113883.5.83"/>    </observationRange>  </referenceRange>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 0..* R -->
  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (dynamic) -->
  </performer>  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) -->
  </author>  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (dynamic) -->
  </informant>  <participant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (dynamic) -->
  </participant></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … *R(Ass…2.0)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1M(Ass…2.0)
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.9.43
Treetree.pnghl7:id
II0 … *R(Ass…2.0)
Treetree.pnghl7:code
CE CWE1 … 1M(Ass…2.0)
 CONF
shall be drawn from concept domain "<<395527009 | Microscopic specimen observable (observable entity) |"
 Example
for use case #1, Breast tubule formation
<code code="371470008" codeSystem="2.16.840.1.113883.6.96"/>
Treetree.pnghl7:text
ED0 … 1R(Ass…2.0)
Treetree.pnghl7:statusCode
CS CNE1 … 1M(Ass…2.0)
 ConstraintThe observation statusCode is “completed” if the observation was actually performed and has produced a result in the value element. In other cases the status of the intended observation is “aborted” and the result will never come.
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS0 … 1R(Ass…2.0)
Treetree.pnghl7:value
INT1 … 1RSingle numerical score item of a scoring system, e.g. "2"  for Breast tubule formation(Ass…2.0)
 Example
for use case #1
<value value="2"/>
Treetree.pnghl7:interpretationCode
CE CWE0 … 1R(Ass…2.0)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)
Treetree.pnghl7:referenceRange
0 … 1R(Ass…2.0)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREVF
Treeblank.pngTreetree.pnghl7:observationRange
0 … 1R(Ass…2.0)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FOBS
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 … 1FEVN.CRT
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CD CWE1 … 1R(Ass…2.0)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.5.4 (Act Code)
Treeblank.pngTreeblank.pngTreetree.pnghl7:text
ED0 … 1R(Ass…2.0)
Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
TS0 … 1R(Ass…2.0)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
ANY1 … 1R(Ass…2.0)
Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretation
CD CWE0 … 1R(Ass…2.0)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)
Treetree.pnghl7:methodCode
CE CWE0 … 1R(Ass…2.0)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (DYNAMIC)
Treetree.pnghl7:performer
II0 … *CPerforming lab

Source: PaLM TF-3: 6.3.2.20

Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC)		(Ass…2.0)
Treetree.pnghl7:author
II0 … *CAuthor

Source: PaLM TF 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)		(Ass…2.0)
Treetree.pnghl7:informant
II0 … *RInformant

Source: PaLM TF 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)		(Ass…2.0)
Treetree.pnghl7:participant
II0 … *RAdditional participants

Source: PaLM TF 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)		(Ass…2.0)
Included1 … *M from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC)
Treetree.pnghl7:specimen
1 … *MRequired 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
Treeblank.pngTreetree.png@typeCode
cs0 … 1FSPC
Treeblank.pngTreetree.pnghl7:specimenRole
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FSPEC
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
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