2.16.840.1.113883.2.6.60.6.10.10/static-2014-07-29T160202

Template	Specimen procedure step Entry / CDAProcedure
Id	2.16.840.1.113883.2.6.60.6.10.10
Version	gültig ab 2014‑07‑29 16:02:02 Status In Entwicklung
Klassifikation	CDA Entry Level Template
Kontext	Elternknoten des Template-Element mit Id 2.16.840.1.113883.2.6.60.6.10.10
Offen/Geschlossen	Offen (auch andere als die definierten Elemente sind erlaubt)
Beschreibung	Template CDA Procedure (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF) for Specimen procedure step in APSR2. This entry collects all the information of source, method and result of a specimen procedure from the collection out of the patient through the final product of a stained histologic section or cytologic smear on a glass slide, or a WSI of such a slide. It reflects the workflow and the probe tracking of a pathology laboratory.
Benutzt von / Benutzt	Benutzt von / Benutzt 17 Templates Benutzt von Template-Id als Name Version 2.16.840.1.113883.2.6.60.6.10.10 Containment CDAProcedure Specimen procedure step Entry 2014‑07‑29 16:02:02 2.16.840.1.113883.2.6.60.6.10.3 ProcedureStepsSection Procedure Steps Section 2014‑05‑13 19:33:12 2.16.840.1.113883.2.6.60.6.10.1 PathologyStructuredReport Pathology Structured Report 2014‑05‑13 11:57:57 Benutzt Template-Id als Name Version 1.2.276.0.76.10.90014 Containment CDAPerformerBody DYNAMIC 1.2.276.0.76.10.90025 Containment CDAAuthorBody DYNAMIC 2.16.840.1.113883.2.6.60.6.10.15 Inklusion CDAParticipantBodyAPSR2 DYNAMIC
Beziehung	Spezialisierung: Template 2.16.840.1.113883.10.12.306 (2005‑09‑07)
Beispiel	Specimen procedure step entry <procedure classCode="PROC" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.3.1.2"/>   <templateId root="1.3.6.1.4.1.19376.1.8.1.4.28"/>   <!-- type of the procedure step, here collection -->   <code code="432550005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Core needle biopsy of breast using ultrasound guidance (procedure)">     <originalText>       <reference value="#A7102400008"/>     </originalText>  </code>  <effectiveTime/>   <!-- Anatomic site -->   <targetSiteCode code="664" codeSystem="1.3.6.1.4.1.19376.1.8.2.1" displayName="Lower outer quadrant" codeSystemName="PATHLEX">     <qualifier>       <name code="272741003" codeSystem="2.16.840.1.113883.6.96" displayName="laterality" codeSystemName="SNOMED-CT"/>       <value code="24028007" codeSystem="2.16.840.1.113883.6.96" displayName="right" codeSystemName="SNOMED-CT"/>     </qualifier>  </targetSiteCode>  <!-- Specimen collector: the surgeon in this case -->   <performer/>   <!-- the specimen collected -->   <participant typeCode="PRD">     <participantRole classCode="SPEC">       <!-- specimen id -->       <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="A7102400008"/>       <playingEntity>         <!-- need a code in PATHLEX for "part obtained from a biopsy -->         <code code="373102004" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen from breast obtained by image guided core biopsy (specimen)" codeSystemName="SNOMED CT"/>       </playingEntity>    </participantRole>  </participant>  <!-- Child procedure step: Production of block A1 -->   <entryRelationship typeCode="COMP">     <procedure classCode="PROC" moodCode="EVN">       <templateId root="1.3.6.1.4.1.19376.1.3.1.2"/>       <templateId root="1.3.6.1.4.1.19376.1.8.1.4.28"/>       <!-- type of the procedure step, here sampling a tissue dice from the part for a block -->       <code code="433465004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Sampling of tissue specimen (procedure)">         <originalText>           <reference value="#block_A_1"/>         </originalText>      </code>      <effectiveTime/>       <targetSiteCode code="85756007" codeSystem="2.16.840.1.113883.6.96" displayName="Body tissue structure (body structure)" codeSystemName="SNOMED CT">         <qualifier>           <!-- a series of codes in PATHLEX would help to describe the exact topographic source of the tissue obtained by trimming and sampling -->           <name code="118169006" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen source topography (attribute)" codeSystemName="SNOMED-CT"/>           <value code="255503000" codeSystem="2.16.840.1.113883.6.96" displayName="Entire (qualifier value)" codeSystemName="SNOMED-CT"/>         </qualifier>      </targetSiteCode>      <!-- Specimen preparator: a member staff of the pathology lab -->       <Performer/>       <!-- the specimen produced -->       <participant typeCode="PRD">         <participantRole classCode="SPEC">           <!-- specimen ids -->           <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="block_A_1"/>           <parentId root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="A7102400008"/>           <playingEntity>             <!-- need a code in PATHLEX for "block extracted from a part -->             <code code="441652008" codeSystem="2.16.840.1.113883.6.96" displayName="Formalin-fixed paraffin-embedded tissue specimen (specimen)" codeSystemName="SNOMED CT"/>           </playingEntity>        </participantRole>      </participant>    </procedure>  </entryRelationship></procedure>
Item DT Kard Konf Beschreibung Label hl7:procedure 1 .. * R (CDAProcedure) @classCode 1 .. 1 F PROC @moodCode cs 1 .. 1 F EVN @negationInd bl 0 .. 1   hl7:templateId II 1 .. 1 R (CDAProcedure) @root 1 .. 1 F 2.16.840.1.113883.10.12.306 hl7:templateId II 1 .. 1 M (CDAProcedure) @root 1 .. 1 F 2.16.840.1.113883.2.6.60.6.10.10 hl7:id II 0 .. * (CDAProcedure) hl7:code CD 1 .. 1 R (CDAProcedure)   Constraint for specimen collection procedure codes for targetSite or PathLex or SNOMED CT have to be used, for specimen processing (down step the procedures) SNOMED CT is preferred, DICOM could be used if available   CONF @code muss "17636008" sein @codeSystem muss "2.16.840.1.113883.6.96" sein @displayName muss "Specimen collection (procedure)" sein @codeSystemName muss "SNOMED CT" sein oder @code muss "40923002" sein @codeSystem muss "2.16.840.1.113883.6.96" sein @displayName muss "Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)" sein @codeSystemName muss "SNOMED CT" sein hl7:text ED 0 .. 1 (CDAProcedure)   Beispiel specimen collection procedure <text>ULTRASOUND GUIDED NEEDLE CORE BIOPSY</text>   Beispiel specimen processing procedure <text>CUTTING A SLIDE FROM A PARAFFIN BLOCK</text> hl7:statusCode CS 0 .. 1 (CDAProcedure)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC) hl7:effectiveTime IVL_TS 0 .. 1 (CDAProcedure) hl7:methodCode CE 0 .. * (CDAProcedure) @codeSystem 1 .. 1 F 2.16.840.1.113883.5.1065 (ProcedureMethod) hl7:target​Site​Code CD 0 .. * (CDAProcedure) @codeSystem 1 .. 1 F 2.16.840.1.113883.5.1052 (Act Site) hl7:performer 0 .. * (CDAProcedure)   Beinhaltet 1.2.276.0.76.10.90014 CDA Performer (Body) (DYNAMIC) hl7:author 0 .. * (CDAProcedure)   Beinhaltet 1.2.276.0.76.10.90025 CDA Author (Body) (DYNAMIC) hl7:participant 0 .. 1 M Warnung: Wenn isMandatory=true dann muss minimumMultiplicity größer 0 sein. (CDAProcedure) Eingefügt von 2.16.840.1.113883.2.6.60.6.10.15 CDA Participant (Body) APSR (DYNAMIC) 1..1 Notwendig   Beispiel Specimen collected or processed <participant typeCode="PRD">   <participantRole classCode="SPEC">     <!-- specimen ids -->     <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="A7102400008"/>     <playingEntity>       <!-- need a code in PATHLEX for "part obtained from a biopsy -->       <code code="theCode" codeSystem="1.3.6.1.4.1.19376.1.8.2.1" displayName="part collected by biopsy" codeSystemName="PATHLEX"/>     </playingEntity>  </participantRole></participant> @typeCode cs 1 .. 1 F PRD @context​Control​Code 1 .. 1 F OP hl7:time IVL_TS 1 .. 1 M (CDAProcedure) hl7:participantRole 1 .. 1 M (CDAProcedure) @classCode 0 .. 1 F SPEC hl7:id II 1 .. 1 M specimen id (CDAProcedure) hl7:id II 0 .. 1 M parent id Warnung: Wenn isMandatory=true dann muss minimumMultiplicity größer 0 sein. (CDAProcedure)   Constraint This Id is the paraentId, i.e. the id of the parent of this specimen. It is not given in specimen collection procedure. hl7:code CE 0 .. 1 optional for specimen collection procedure (CDAProcedure) @code 1 .. 1 F P @codeSystem 1 .. 1 F 2.16.840.1.113883.5.111 (Role Code) @codeSystemName 1 .. 1 F HL7 Eingefügt von 2.16.840.1.113883.2.6.60.6.10.16 CDA PlayingEntity APSR2 (DYNAMIC) 0..* @classCode 0 .. 1 F ENT @determiner​Code 0 .. 1 F INSTANCE hl7:code CE 0 .. * Codes for - classCode - typeCode - subTypeCode - isDerived - specimenRole - specimenChildRole - specimenGroupCount (CDAProcedure)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.16040 EntityCode (DYNAMIC) oder @code muss "see example " sein oder @code muss "119376003" sein @codeSystem muss "2.16.840.1.113883.6.96" sein @displayName muss "Tissue, unspecified" sein @codeSystemName muss "SNOMED-CT" sein oder @code muss "TISS" sein @codeSystem muss "2.16.840.1.113883.5.129" sein @codeSystemName muss "HL7" sein   Beispiel example for PathLex <playingEntity>   <!-- Need codes in PathLex for "part obtained by e.g.biopsy" -->   <code code="theCode" codeSystem="1.3.6.1.4.1.19376.1.8.2.1" displayName="part collected by e.g.biopsy" codeSystemName="PathLex"/> </playingEntity> hl7:quantity PQ 0 .. * (CDAProcedure) hl7:name PN 0 .. * (CDAProcedure) hl7:desc ED 0 .. * (CDAProcedure) hl7:entryRelationship 0 .. 2 (CDAProcedure)   Beinhaltet 2.16.840.1.113883.2.6.60.6.10.10 Specimen procedure step Entry (DYNAMIC)