cdapath:Klinische Information-Section (Template)

Section: Klinische Information

Template ID	1.3.6.1.4.1.19376.1.8.1.2.1 (AP APSR 6.2.4.1)
General Description	In diesem Abschnitt werden die Daten zu Klinischen Angeben übermittelt.
Status	identisch zu IHE
LOINC Code	Opt.	Description
22636-5	R2	Klinische Angaben

Definition und Zweck

Die klinische Information Section enthält diejenigen informationen, die der Einsender bereitstellt: Anamnes, prä- u./o. postoperative (Verdachts-)Diagnose, Anlass der Untersuchung, Laborwerte, Entnahmestelle, Materialtyp, klinische Materialbeschreibung, Tumorlokalisation.

Beispiel

<section>
  <templateId root='1.3.6.1.4.1.19376.1.8.1.2.1'/>
  <code code='22636-5' displayName='Pathology report relevant history'
        codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>CLINICAL INFORMATION SECTION</title>
  <text>
     Material: Biopsie linke Brust und apikales axilläres Gewebe links  
  </text> 
  
  <entry typeCode='COMP'>
    <templateId root='1.3.6.1.4.1.19376.1.8.1.3.1'/>
    <!-- Specimen Information Organizer -->
       <organizer classCode='CLUSTER' moodCode='EVN'> 
       <templateId root='1.3.6.1.4.1.19376.1.8.1.4.4'/>
       <statusCode code='completed'/>
       <!-- Specimen collection procedure -->
          <component>
            <procedure classCode='PROC' moodCode='EVN'> 
            <templateId root='1.3.6.1.4.1.19376.1.3.1.2'/>
            <code code='310638008'
                  codeSystem='2.16.840.1.113883.6.96' displayName='Drahtmarkierte radiologisch kontrollierte Tumorexzision Brust' codeSystemName='SNOMED-CT'/> 
                  <effectiveTime>
                     <low value="201012150905"/>
                     <high value="201012150935"/>
                  </effectiveTime>
            <targetSiteCode code="76752008" 
                            codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" 
                               displayName="Breast structure">
                  <qualifier>
                     <name code="272741003" displayName="laterality"
                           codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
                     <value code="7771000" displayName="left" 
                           codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/>
                  </qualifier>
</targetSiteCode>
<!-- Specimen collector: the surgeon in this case -->
<performer> 
<assignedEntity>
<id />
<addr nullFlavor="NASK"/>
<telecom value="tel:0147150000" use="EC"/>
<assignedPerson> 
<name>
<prefix>Doctor</prefix>
<given>Eva</given>
<family>Surgeon</family>
</name> 
</assignedPerson>
<representedOrganization>
<name>Hospital Lullaby</name>
</representedOrganization>
</assignedEntity> 
</performer>
<!-- the specimen collected -->
<participant typeCode="PRD">
<participantRole classCode="SPEC">
<!-- specimen ids --> 
<id root="1.3.6.1.4.1.19376.1.8.9.7" extension="0102030405"/>
<playingEntity>
<!-- Specimen type -->
<code code="309546004" 
codeSystem="2.16.840.1.113883.6.96" displayName="Lumpectomy breast sample (specimen)"/>
</playingEntity>
</participantRole>
</participant>
</procedure> 
</component>
<!-- Problem organizer -->
<component>
<organizer classCode="BATTERY" moodCode="EVN"> 
<templateId root="1.3.6.1.4.1.19376.1.8.1.4.8"/>
<statusCode code="completed"/>
<component>
<observation classCode="OBS" moodCode="EVN">
<code code="7" codeSystemName="PATHLEX"  
codeSystem="1.3.6.1.4.1.19376.1.8.2.1" displayName="tumor location in the organ"/>
<statusCode code="completed"/>
<value xsi:type="CD" code="76365002"
codeSystem="2.16.840.1.113883.6.96"
displayName="Structure of upper outer quadrant of breast (body structure)"/> 
</observation>
</component>
</organizer>
</component>
</organizer> 
</entry>
<!-- Sub-sections -->
<component>
<section> 
<templateId root= '1.3.6.1.4.1.19376.1.5.3.1.3.1'/>
<code code='42349-1' displayName= ‘Reason for referral’
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<title>Reason for anatomic pathology procedure</title>
<text>Breast mass - left breast</text> 
</section>
</component>
<component>
<section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/> 
<code code=’10164-2’ displayName= ‘History of present illness’
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<title> History of present illness </title>
<text>Carcinoma of breast. Post operative diagnosis: same.
left UOQ breast mass. 
</text>
</section>
</component>
</component>
:
</component>
</section>
</component>