2.16.840.1.113883.2.6.60.6.10.9/static-2014-05-14T170954

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Template AP Observation Entry / APObservationEntry
Id2.16.840.1.113883.2.6.60.6.10.9
Version gültig ab 2014‑05‑14 17:09:54 Status Kyellow.png In Entwicklung
KlassifikationCDA Entry Level Template
KontextElternknoten des Template-Element mit Id 2.16.840.1.113883.2.6.60.6.10.9
Offen/GeschlossenGeschlossen (nur definierte Elemente sind erlaubt)
Beschreibung 
                   
                       
                           Template CDA Observation (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF).

This Content Module is usable within a Problem Organizer.

The “AP Observation” generic template is usable for all AP observations, including ancillary techniques.

Each specific AP observation is associated to a specific template, child of the “AP Observation” generic template. This specific child template has exactly the same structure as the generic one, and brings only a number of vocabulary constraints related to the type of observation and to the type of organ source of the specimen observed: 

  • The code for the specific observation, defined as a value set bound to the observation/code element, containing a single triplet (code, codeSystem, displayName) representing this specific observation.
  • The cardinalities and default type for the observation/value element carrying the results of this observation.
  • The domain of values for this observation in case these values are coded. This domain of coded values is defined as a value set bound to the observation/value element, containing as many triplets (code, codeSystem, displayName) as there are admissible result values for this specific observation performed on a specimen taken from this specific organ.

An AP observation has a status and an effective time, may describe various participants (persons, devices, organizations), may have a number of additional properties (method, interpretation, text), and may contain embedded images, comments, and sub-observations, which are also AP observations.
Assoziiert mit
Assoziiert mit 1 Konzept
IdNameDatensatz
psr-data​element-47PSR
Benutzt von / Benutzt
Benutzt von / Benutzt 33 Templates
Benutzt von Template-Id als NameVersion
2.16.840.1.113883.2.6.60.6.10.36TNMGrading TNM Grading2015‑11‑15 13:01:18
2.16.840.1.113883.2.6.60.6.10.14Link.pngTNMObservation TNM Observation2014‑05‑13 15:45:13
2.16.840.1.113883.2.6.60.6.10.34Link.pngProblemOrganizer Problem Organizer2015‑08‑13 10:24:55
2.16.840.1.113883.2.6.60.6.10.2Link.pngIntraoperativeObservationSection Intraoperative Observation Section2014‑05‑13 19:29:16
2.16.840.1.113883.2.6.60.6.10.1Link.pngPathologyStructuredReport Pathology Structured Report2014‑05‑13 11:57:57
2.16.840.1.113883.2.6.60.6.10.4Link.pngDiagnosticConclusionSection Diagnostic Conclusion Section2014‑05‑13 19:31:26
2.16.840.1.113883.2.6.60.6.10.5Link.pngClinicalInformationSection Clinical Information Section2014‑05‑13 14:38:08
2.16.840.1.113883.2.6.60.6.10.6Link.pngMicroscopySection Microscopic Observation Section2014‑05‑13 14:25:17
2.16.840.1.113883.2.6.60.6.10.7Link.pngMacroscopySection Macroscopic Observation Section2014‑05‑13 11:57:09
Benutzt Template-Id als NameVersion
2.16.840.1.113883.2.6.60.6.10.13ContainmentSpecimenIdentification DYNAMIC
1.2.276.0.76.10.90014ContainmentCDAPerformerBody DYNAMIC
1.2.276.0.76.10.90025ContainmentCDAAuthorBody DYNAMIC
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Beispiel
Observation example
<observation negationInd="false" classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.12.303"/>
  <templateId root="2.16.840.1.113883.2.6.60.6.10.9"/>
  <id root="1.2.3.999" extension="--example only--"/>
  <code/>
  <derivationExpr/>
  <text/>
  <statusCode code="normal"/>
  <effectiveTime>
    <low value="20141217162315"/>
  </effectiveTime>  <priorityCode code="A" displayName="ASAP" codeSystem="2.16.840.1.113883.5.7"/>
  <repeatNumber/>
  <languageCode code=""/>
  <value xsi:type="CD"/>
  <interpretationCode code="Carrier" displayName="Carrier" codeSystem="2.16.840.1.113883.5.83"/>
  <methodCode code="0001" displayName="Complement fixation" codeSystem="2.16.840.1.113883.5.84"/>
  <targetSiteCode/>
  <subject>
    <!-- template CDASubjectBody (dynamic) -->
  </subject>  <specimen>
    <!-- template Specimen Identification (dynamic) -->
  </specimen>  <performer>
    <!-- template CDAPerformerBody (dynamic) -->
  </performer>  <author>
    <!-- template CDAAuthorBody (dynamic) -->
  </author>  <informant>
    <!-- template CDAinformantBody (dynamic) -->
  </informant>  <participant>
    <!-- template CDAParticipantBody (dynamic) -->
  </participant>  <entryRelationship negationInd="false" typeCode="CAUS" inversionInd="false" contextConductionInd="false">
    <sequenceNumber value="1"/>
    <seperatableInd value="false"/>
    <reference>
      <!-- template CDAReference (dynamic) -->
    </reference>    <precondition>
      <!-- template CDAPrecondition (dynamic) -->
    </precondition>    <referenceRange typeCode="REFV">
      <observationRange classCode="OBS" moodCode="EVN.CRT">
        <code/>
        <text/>
        <value xsi:type="ANY"/>
        <interpretationCode code="Carrier" displayName="Carrier" codeSystem="2.16.840.1.113883.5.83"/>
      </observationRange>    </referenceRange>  </entryRelationship></observation>
ItemDTKardKonfBeschreibungLabel
hl7:observation
0 .. *(APObservationEntry)
Treetree.png@classCode
1 .. 1FOBS
Treetree.png@moodCode
cs1 .. 1FEVN
Treetree.png@negationInd
bl0 .. 1 
 Target.pngZiel der Konzept Id(s):
psr-data​element-47
Treetree.pnghl7:templateId
II1 .. 1R(APObservationEntry)
Treeblank.pngTreetree.png@root
1 .. 1F2.16.840.1.113883.10.12.303
Treetree.pnghl7:templateId
II1 .. 1M(APObservationEntry)
Treeblank.pngTreetree.png@root
1 .. 1F2.16.840.1.113883.2.6.60.6.10.9
Treetree.pnghl7:id
II0 .. *(APObservationEntry)
Treetree.pnghl7:code
CD1 .. 1M(APObservationEntry)
Treeblank.pngTreetree.png@codeSystem
1 .. 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
1 .. 1FLOINC
 Beispiel<code code="59847-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Histology and Behavior ICD-O-3"/>
Treetree.pnghl7:derivationExpr
ST0 .. 1(APObservationEntry)
Treetree.pnghl7:text
ED0 .. 1RTextual description of the observation, offered by the system
(APObservationEntry)
Treetree.pnghl7:statusCode
CS0 .. 1(APObservationEntry)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS0 .. 1RDate and time the observation has been made, offered by the system(APObservationEntry)
Treetree.pnghl7:priorityCode
CE0 .. 1(APObservationEntry)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
Treetree.pnghl7:repeatNumber
IVL_INT0 .. 1(APObservationEntry)
Treetree.pnghl7:language​Code
CS0 .. 1(APObservationEntry)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
Treetree.pnghl7:value
CD1 .. 1R(APObservationEntry)
 ConstraintThe default data type, cardinalities and value set for the <value> element are dependant of the type of observation.
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.2.6.60.6.11.34 AP Observation (DYNAMIC)
 Beispiel<value code="8500/3" codeSystem="2.16.840.1.113883.6.43.1" codeSystemName="ICD-O-3" displayName="Invasive carcinoma of the breast, no special type"/>
Treetree.pnghl7:interpretationCode
CE0 .. *(APObservationEntry)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)
Treetree.pnghl7:methodCode
CE0 .. *(APObservationEntry)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.14079 ObservationMethod (DYNAMIC)
Treetree.pnghl7:target​Site​Code
CD0 .. *(APObservationEntry)
Treeblank.pngTreetree.png@codeSystem
1 .. 1F2.16.840.1.113883.5.1052 (Act Site)
Treetree.pnghl7:specimen
1 .. 1M(APObservationEntry)
 Constraintin this entry template only "specimen role" is used with the id given in specimen procedure step entry for that specimen the observation is made on.
 Beispiel
Example for specimen referencing
<specimen>
  <!-- which specimen is used for this observation -->
  <specimenRole>
    <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="slide_A_1_PR"/>
  </specimenRole></specimen>
 Beinhaltet 2.16.840.1.113883.2.6.60.6.10.13 Specimen Identification (DYNAMIC)
Treetree.pnghl7:performer
0 .. *(APObservationEntry)
 Beinhaltet 1.2.276.0.76.10.90014 CDA Performer (Body) (DYNAMIC)
Treetree.pnghl7:author
0 .. *(APObservationEntry)
 Beinhaltet 1.2.276.0.76.10.90025 CDA Author (Body) (DYNAMIC)
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