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Inhaltsverzeichnis

1 Foreword
2 Introduction to this Supplement
- 2.1 Open Issues and Questions
- 2.2 Closed Issues
3 VOLUME 1 - PROFILES
4 VOLUME 3 – CONTENT MODULES
5 1 Introduction
6 2 Content Modules – Basic Principles
7 3 IHE Transactions
- 7.1 3.1 Cross Enterprise Document Content Transactions
8 4 IHE Anatomic Pathology Bindings
9 5 Namespaces and Vocabularies
10 6 Anatomic Pathology Content Modules
- 10.1 6.1 Conventions
- 10.2 6.2 HL7 CDA R2 Content Modules
11 VOLUME 4 - VALUE SETS

Foreword

This is a supplement to the IHE Pathology and Laboratory Medicine Technical Framework V7.0. Each supplement undergoes a process of public comment and trial implementation before being incorporated into the volumes of the Technical Frameworks.

This supplement is published on <Month XX, 2016> for Public Comment. Comments are invited and may be submitted at http://www.ihe.net/<domain>/<domain>comments.cfm. In order to be considered in development of the Trial Implementation version of the supplement, comments must be received by <Month XX, 201X>.

This supplement describes changes to the existing technical framework documents.

“Boxed” instructions like the sample below indicate to the Volume Editor how to integrate the relevant section(s) into the relevant Technical Framework volume.

Replace Section X.X by the following:

Where the amendment adds text, make the added text bold underline. Where the amendment removes text, make the removed text bold strikethrough. When entire new sections are added, introduce with editor’s instructions to “add new text” or similar, which for readability are not bolded or underlined.

General information about IHE can be found at: http://www.ihe.net.

Information about the IHE Pathology and Laboratory Medicine domain can be found at: http://ihe.net/IHE_Domains.

Information about the structure of IHE Technical Frameworks and Supplements can be found at: http://ihe.net/IHE_Process and http://ihe.net/Profiles.

The current version of the IHE Technical Framework (if applicable) can be found at: http://ihe.net/Technical_Frameworks.

<Comments may be submitted on IHE Technical Framework templates any time at http://ihe.net/ihetemplates.cfm. Please enter comments/issues as soon as they are found. Do not wait until a future review cycle is announced.

Introduction to this Supplement

This supplement complements volume 1 of the PaLM technical framework with the description of the APSR 2.0 content profile, and volumes 3 and 4 with the bindings, content modules and value sets, which specify this profile.

Open Issues and Questions

None yet

Closed Issues

APSR-07 – Representing the hierarchy of specimens in an entry : This APSR supplement enables to represent the hierarchy of specimens at the CDA level 3. The operations on specimen and production of child specimens are tracked in the “Procedure Steps” section, which has a level 3 entry.

APSR-10 – Observation related to multiple specimens: For example tumor staging may require combining data from multiple specimens (e.g., a breast excision with positive margins followed by a re-excision with clear margins – in this case the tumor size may be a composite of measurements from both specimens. Another example is staging of ovarian carcinomas with multiple biopsies of pelvis, peritoneum, nodes, omentum, etc.). To accommodate these use cases, the specimen organizer is able to represent either a single specimen or a group of specimens investigated together.

APSR-11 – Derivative specimens:Specimens derived from primary specimens for ancillary studies, which may be sent to a reference lab or done in another part of the same institution, are included in the scope of this profile. The results produced on a derived specimen are attached to this specimen in the report.

VOLUME 1 - PROFILES

10 Anatomic Pathology Structured Report (APSR) Profile

This content profile describes an anatomic pathology structured report (APSR) as a digital document to be shared or exchanged between pathology laboratories and other care providers and institutions.

Anatomic pathology structured reports document the findings on specimens removed from patients for diagnostic or therapeutic reasons. This information can be used for patient care, clinical research and epidemiology. Standardizing and computerizing anatomic pathology reports is necessary to improve the quality of reporting and to facilitate the exchange the exchange and reuse of the content of these reports.

This content profile describes a digital anatomic pathology report shared in a human-readable format, which may include images, and which also contains findings and observations in a machine-readable format, to facilitate the integration of these into the database of a consumer system, and to enable the application of automated reasoning to this content.

The scope of this IHE content profile covers all fields of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as cytopathology.

Goldsmith, J.D., et al., “Reporting guidelines for clinical laboratory reports in surgical pathology” Arch Pathol Lab Med, 2008. 132(10): p. 1608-16, is the first source of specification for this content profile. This article delineates the required, preferred, and optional elements which should be included in any report of surgical pathology.

This source is complemented by the “cancer checklists” produced by the College of American Pathologists, and by the “comptes rendus d’anatomopathologie : données minimales à renseigner pour une tumeur primitive” produced by the French society of pathology (SFP [1]) for the French cancer institute (INCa [www.e-cancer.fr]).

This profile has also benefited from the guidance on cancer AP reports provided by the North-American Association of Central Cancer Registries; some of the example snippets captured in the profile leverage the NAACCR Standards for Cancer Registries, Volume V, Pathology Laboratory Electronic Reporting.

10.1 APSR Actors/Transactions

This section defines the actors, transactions, and/or content modules in this profile. General definitions of actors are given in the Technical Frameworks General Introduction Appendix A published here.

Figure 10.1-1 shows the actors directly involved in the APSR Profile and the direction that the content is exchanged.

A product implementation using this profile must group actors from this profile with actors from a workflow or transport profile to be functional. The grouping of the content module described in this profile to specific actors is described in more detail in the “Required Actor Groupings” section below.

Figure 10.1-1 APSR Actor Diagram

Table 10.1-1 lists the content module(s) defined in the APSR profile. To claim support with this profile, an actor shall support all required content modules (labeled “R”) and may support optional content modules (labeled “O”).

Table 10.1-1: <Profile Acronym>Profile - Actors and Content Modules

Actors	Content Modules	Optionality	Reference
Content Creator	Anatomic Pathology Structured Report 1.3.6.1.4.1.19376.1.8.1.1.1	R	PaLM TF-3: 6.3.1.2
Content Consumer	Anatomic Pathology Structured Report 1.3.6.1.4.1.19376.1.8.1.1.1	R	PaLM TF-3: 6.3.1.2

10.1.1 Actor Descriptions and Actor Profile Requirements

Most requirements are documented in Content Modules (Volume 3). This section documents any additional requirements on profile’s actors.

10.2 APSR Actor Options

Options that may be selected for each actor in this profile are listed in the table 10.2-1. These options are further detailed in PCC Technical Framework Volume 2 as indicated in the rightmost column.

Table 10.2-1 Anatomic Pathology Structured Report - Actors and Options

Actor

Option Name

Reference

Content

Creator

None

Content

Consumer

View Option (1)

Document Import Option (1)

Section Import Option (1)

PCC TF-2:3.1.1

PCC TF-2:3.1.2

PCC TF-2:3.1.3

Note 1: The Content Consumer Actor shall support at least one of these options.

10.3 APSR Required Actor Groupings

An Actor from this profile (Column 1) shall implement all of the required transactions and/or content modules in this profile in addition to all of the transactions required for the grouped actor (Column 2).

In some cases, required groupings are defined as at least one of an enumerated set of possible actors; this is designated by merging column one into a single cell spanning multiple potential grouped actors. Notes are used to highlight this situation.

Section 10.5 describes some optional groupings that may be of interest for security considerations and section 10.6 describes some optional groupings in other related profiles.

Table 10.3-1: Anatomic Pathology Structured Report - Required Actor Groupings

XD-LAB Actor

Actor to be grouped with

Reference

Content Bindings Reference

Content

Creator

ITI XDS.b Document Source

OR

ITI XDM Portable Media Creator

OR

ITI XDR Document Source

ITI TF-1:10

ITI TF-1:16

ITI TF-1:15

Content

Consumer

ITI XDS.b Document Consumer

OR

ITI XDM Portable Media Consumer

OR

ITI XDR Document Recipient

ITI TF-1:10

ITI TF-1:16

ITI TF-1:15

Note 1: Each actor of APSR SHALL be grouped with at least one of the ITI actors listed in its table row.

10.4 APSR Overview

10.4.1 Concepts

This content profile represents a common digital document model applicable to any structured report for surgical pathology in all fields of anatomic pathology (cancers, benign neoplasms, non-neoplastic conditions) as well as for cytopathology.

This common model is composed of a header conveying the context of care (patient, care providers, pathologists, laboratories, order, act documented …) and a body. The body organizes the human-readable content of the report in a number of sections. Each section may also provide machine-readable content in an “entry” embedded in the section. This common model defines the order of appearance, cardinalities and internal structure of each section, and of each entry embedded in each section.

Figure 10.4.1-1 shows this general model applicable to any pathology digital report.

Figure 10.4.1-1 Common model for a digital anatomic pathology report

Note 1: The only section that is mandatory is the Diagnostic Conclusion section.

10.4.2 Use Cases

10.4.2.1 Use case #1: Single Report

Anatomic pathology order fulfilled by a pathology laboratory produces a report.

10.4.2.1.1 Single Report Use Case Description

A surgeon removes a breast tumor from a patient, requests the procedure “breast surgical specimen - pathological examination” and sends the specimen(s) to the anatomic pathology laboratory. Specimens) are accessioned by the anatomic pathology laboratory. The staff performs a macroscopic examination of the specimens ; gross imaging is performed if needed. The specimens are processed for microscopic examination and other special ancillary techniques or tissue banking if needed. During the imaging interpretation process, microscopic imaging is performed if needed. At the end of the interpretation process the pathologist queries the Content Creator application for the appropriate APSR template, fills the form, binds some relevant images and/or regions of interest to specific observations, validates and signs the digital report.

10.4.2.1.2 Single Report Process Flow

Intentionally left blank

10.4.2.1.3 Single Report Example

A. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY):

INVASIVE ADENOCARCINOMA OF THE BREAST. HISTOLOGIC TYPE: DUCTAL. NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3. TUBULE FORMATION SCORE: 2. NUCLEAR PLEOMORPHISM SCORE: 2. MITOTIC RATE SCORE: 1.

IN-SITU CARCINOMA: EQUIVOCAL.

BREAST CANCER BIOMARKER STUDIES: PARAFFIN BLOCK NUMBER: A1.

ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8).

PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED SCORE = 8).

DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR EXPRESSION OF

EPIDERMAL GROWTH FACTOR RECEPTOR.

HER2/NEU IMMUNOHISTOCHEMISTRY: POSITIVE (3+) FOR OVEREXPRESSION OF HER2/NEU

ONCOPROTEIN.

10.4.2.2 Use Case #2: Multi-step Report

Reporting includes multiple successive steps.

10.4.2.2.1 Multi-step Report Use Case Description

A surgeon removes a breast tumor from a patient, requests the procedure “breast surgical specimen - frozen sections & pathological examination”, and “breast surgical specimen - pathological examination” and sends the specimen(s) to the anatomic pathology laboratory.

Specimens are accessioned by the anatomic pathology department. The staff performs a macroscopic examination of the specimens, gross imaging is performed if needed. The specimens are processed for intraoperative observation if needed, and tissue banking if needed (e.g., for research purpose). During the imaging interpretation process of frozen sections, microscopic imaging is performed if needed. At the end of the interpretation process, the pathologist queries the Content Creator for the appropriate APSR template, fills the intraoperative observation section, binds some relevant images and/or regions of interest to specific observation(s) if needed, validates and signs (i.e., legally authenticates) the preliminary APSR.

The day after, the specimen(s) are processed for microscopic examination and other special ancillary techniques if needed. During the imaging interpretation process, microscopic imaging is performed if needed. At the end of the interpretation process, pathologist queries the Content Creator for the preliminary APSR, fills the form, binds some relevant images and/or regions of interest to specific observation(s), validates and signs (i.e., legally authenticates) the final APSR.

10.4.2.2.2 Multi-step Report Process Flow

Intentionally left blank

10.5 APSR Security Considerations

See Appendix A of PaLM TF-1.

10.6 APSR Cross Profile Considerations

Intentionally left blank

VOLUME 3 – CONTENT MODULES

1 Introduction

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1.1 Overview of the Anatomic Pathology Technical Framework

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1.2 Overview of Volume 3

The IHE Technical Framework is based on actors that interact through transactions using some form of content.

Actors are information systems or components of information systems that produce, manage, or act on information associated with operational activities in the enterprise.

Transactions are interactions between actors that transfer the required information through standards-based messages.

Content profiles specify how the payload of a transaction fits into a specific use of that transaction. A content profile has three main parts. The first part describes the use case. The second part is binding to a specific IHE transaction, which describes how the content affects the transaction. The third part is a Content Module, which describes the payload of the transaction. A content module is specified so as to be independent of the transaction in which it appears. This overall content module is itself an assemblage of smaller content modules, which in turn may assemble smaller content modules, conforming to the chosen standard.

In particular, the Pathology and Laboratory Medicine Technical Framework provides a set of content profiles for the sharing of persistent clinical document produced by the anatomic pathology domain.

This Volume 3 specifies the content modules produced at various granularity levels (from a whole clinical document to a tiny reusable piece of coded data) by the Anatomic Pathology domain of IHE for its own content profiles.

Some of these content modules produced here, may be used by content modules of higher granularity from other domains (e.g., Patient Care Coordination).

Some of these content modules produced here, may leverage content modules of lower granularity from other domains (e.g., PCC, RAD, etc.).

1.3 Audience

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1.4 Relationship to Standards

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1.5 Relationship to Real World Architecture

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1.6 Conventions

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1.7 Scope Introduced in the Current Year

Content Modules for the APSR Profile

1.8 Copyright Permission

Health Level Seven, Inc. has granted permission to the IHE to reproduce tables from the HL7 standard. The HL7 tables in this document are copyrighted by Health Level Seven, Inc. All rights reserved. Material drawn from these documents is credited where used.

1.9 Glossary

The glossary of the Anatomic Pathology Technical Framework is centralized in former PAT TF-1:1.12.

2 Content Modules – Basic Principles

This Volume 3 of the Suppl. APSR 2.0 to the PaLM TF organizes content modules categorically by the base standard. At present, former PAT TF-3 uses only one base standard, CDA Release 2.0, but this is expected to change over time. Underneath each standard, the content modules are organized using a very coarse hierarchy inherent to the standard.

Each content module can be viewed as the definition of a "class" in software design terms, and has associated with it a name. Like "class" definitions in software design, a content module is a "contract", and the former PAT TF-3 defines that contract in terms of constraints that must be obeyed by instances of that content module. Each content module has a name, also known as its template identifier. The template identifiers are used to identify the contract agreed to by the content module. The Pathology and Laboratory Medicine Technical Committee is responsible for assigning the template identifiers to each content module.

Like classes, content modules may inherit features of other content modules of the same type (e.g., Document, Section or Entry) by defining the parent content module that they inherit from. They may not inherit features from a different type.

Constraints that apply to any content module will always apply to any content modules that inherit from it. Thus, the "contracts" are always valid down the inheritance hierarchy.

The former PAT TF-3 uses the convention that a content module cannot have more than one parent (although it may have several ancestors). This convention is not due to any specific technical limitation of the technical framework, but does make it easier for software developers to implement content modules.

Each content module has a list of data elements that are required (R), required if known (R2), conditional (C) or optional (O).

Other data elements may be included in an instance of a content module over what is defined by the former PAT TF-3. Content consumers are not required to process these elements, and if they do not understand them, must ignore them. Thus, it is not an error to include more than is asked for, but it is an error to reject a content module because it contains more than is defined by the framework. This allows value to be added to the content modules delivered internationally in this framework, through national extensions built by the national IHE organizations in various countries. It further allows content modules to be defined later by IHE that are refinements or improvements over previous content modules.

3 IHE Transactions

This section defines each IHE transaction in detail, specifying the standards used, and the information transferred.

3.1 Cross Enterprise Document Content Transactions

At present, all transactions used by the Anatomic Pathology Content Profiles appear in ITI TF-2a and ITI TF-2b.

General Options defined in content profiles for a Content Consumer are listed below.

3.1.1 View Option

A Content Consumer that supports the View Option shall be able to:

1. Use the appropriate XD* transactions to obtain the document along with associated necessary metadata.

2. Render the document for viewing. This rendering shall meet the requirements defined for CDA Release 2 content presentation semantics (See Section 1.2.4 of the CDA Specification: Human readability and rendering CDA Documents). CDA Header information providing context critical information shall also be rendered in a human readable manner. This includes at a minimum the ability to render the document with the stylesheet specifications provided by the document source, if the document source provides a stylesheet. Content Consumers may optionally view the document with their own stylesheet, but must provide a mechanism to view using the source stylesheet.

3. Support traversal of links for documents that contain links to other documents managed within the sharing framework.

4. Print the document to paper.

3.1.2 Document Import Option

This Option requires that the View Option be supported. In addition, the Content Consumer that supports the Document Import Option shall be able to support the storage of the entire APSR document (as provided by the sharing framework, along with sufficient metadata to ensure its later viewing). The machine-readable content (from the entry elements) shall also be imported. This Option requires the proper tracking of the document origin. Once a document has been imported, the Content Consumer shall offer a means to view the document without the need to retrieve it again from the sharing framework. When the document is used after it was imported, a Content Consumer may choose to access the sharing framework to find out if the related Document viewed has been deprecated or replaced.

3.1.3 Section Import Option

This Option requires that the View Option be supported. In addition, the Content Consumer that supports the Section Import Option shall be able to support the import of one or more sections of the APSR document (along with sufficient metadata to link the data to its source). The machine-readable content (from the entry elements beneath the imported sections) shall also be imported. This Option requires the proper tracking of the document section origin. Once sections have been selected, a Content Consumer shall offer a means to copy the imported section(s) into local data structures. When a section is used after it is imported, a Content Consumer may choose to access the sharing framework to find out if the related information has been updated.

4 IHE Anatomic Pathology Bindings

This section describes how the payload used in a transaction of an IHE profile is related to and/or constrains the data elements sent or received in those transactions. This section is where any specific dependencies between the content and transaction are defined.

A content profile can define multiple bindings. Each binding should identify the transactions and content to which it applies.

The source for all required and optional attributes have been defined in the bindings below. Three tables describe the three main XDS object types: XDSDocumentEntry, XDSSubmissionSet, and XDSFolder. XDSSubmissionSet and XDSDocumentEntry are required. Use of XDSFolder is optional. These concepts are universal to XDS, XDR and XDM.

The structure of these three tables is presented in PCC TF-2:4

4.1 Anatomic Pathology Document Binding to XDS, XDM and XDR

This binding defines a transformation that generates metadata for the XDSDocumentEntry element of appropriate transactions from the XDS, XDM and XDR profiles given a medical document and information from other sources. The medical document refers to the document being stored in a repository that will be referenced in the registry. The other sources of information include the configuration of the Document Source actor, the Affinity Domain, the site or facility, local agreements, other documents in the registry/repository, and this content profile.

In many cases, the CDA document is created for the purposes of sharing within an affinity domain. In these cases the context of the CDA and the context of the affinity domain are the same, in which case the following mappings shall apply.

In other cases, the CDA document may have been created for internal use, and are subsequently being shared. In these cases the context of the CDA document would not necessarily coincide with that of the affinity domain, and the mappings below would not necessarily apply.

4.1.1XDS DocumentEntry Metadata

The general table describing the XDSDocumentEntry Metadata requirements for IHE domains is shown in PCC TF-2:4.1.1

The sub-sections below list the only requirements which are specific to the Anatomic Pathology Domain, and which supersede those from the general table mentioned above.

4.1.1.1XDS DocumentEntry.formatCode

The values of formatCode per document template are listed in table 5.6-1.

The associated codingScheme Slot SHALL be 1.3.6.1.4.1.19376.1.2.3 in all cases.

4.1.1.2XDS DocumentEntry.eventCodeList

This metadata provides a means to index anatomic pathology reports by reportable conditions (e.g., certain types of tumors…) so as to facilitate later queries in a registry of shared clinical documents. The conclusions coded in the entry element of the Diagnostic Conclusion section are good candidates for this metadata.

4.1.1.3XDS DocumentEntry.parentDocumentRelationship

The Anatomic Pathology document Content Modules only permit the “replace” relationship between instances of APSR documents.

Thus, XDSDocumentEntry.parentDocumentRelationship is constrained to the "RPLC" (replace) value. The new document issued replaces completely the parent one, which will be considered as deprecated.

4.1.2XDS SubmissionSet Metadata

The submission set metadata is as defined for XDS, and is not necessarily affected by the content of the clinical document. Metadata values in an XDSSubmissionSet with names identical to those in the XDSDocumentEntry may be inherited from XDSDocumentEntry metadata, but this is left to affinity domain policy and/or application configuration.

This content format uses the submission set to create a package of information to send from one provider to another. All documents or images referenced by the Anatomic Pathology Structured Report in this Package must be present (at least as references in the case of images) in the submission set.

4.1.3XDS Folder Metadata

No specific requirements identified.

4.1.4 Configuration

The Anatomic Pathology Content Profiles using this binding require that Content Creators and Content Consumers be configurable with institution and other specific attributes or parameters. Implementers should be aware of these requirements to make such attributes easily configurable.

5 Namespaces and Vocabularies

5.1 OID tree of PAT TF

1.3.6.1.4.1.19376.1.81.3.6.1.4.1.19376.1.8 is the OID of the former IHE Anatomic Pathology domain, whereas 1.3.6.1.4.1.19376.1.81.3.6.1.4.1.19376.1.3 is the OID for PaLM domain :

All exchangeable objects specified by these domains are identified by OIDs built on these roots:

Branch 1.3.6.1.4.1.19376.1.8.1 is dedicated to CDA Content Modules created by the AP domain

       Sub-branch 1.3.6.1.4.1.19376.1.8.1.1 is the OID of the generic Document Content Module		
       Sub-branch 1.3.6.1.4.1.19376.1.8.1.2 is dedicated to Section Content Modules		
       Sub-branch 1.3.6.1.4.1.19376.1.8.1.4 is dedicated to Element Content Modules	
       Sub-branch 1.3.6.1.4.1.19376.1.8.1.4.8 is the OID of the Problem Organizer
       Sub-branch 1.3.6.1.4.1.19376.1.8.1.4.9 is the OID of the generic anatomic pathology (AP) observation template

Branch 1.3.6.1.4.1.19376.1.8.2 is dedicated to terminologies defined by AP domain

       Sub-branch 1.3.6.1.4.1.19376.1.8.2.1 is dedicated to PathLex

Branch 1.3.6.1.4.1.19376.1.8.5 is dedicated to Value Sets defined by AP domain.

Branch 1.3.6.1.4.1.19376.1.3.10 is dedicated to Templates newly defined by PaLM domain.

       Sub-branch 1.3.6.1.4.1.19376.1.3.10.1 is dedicated to CDA Document Level Templates
       Sub-branch 1.3.6.1.4.1.19376.1.3.10.2 is dedicated to CDA Header Level Templates
       Sub-branch 1.3.6.1.4.1.19376.1.3.10.3 is dedicated to CDA Section Level Templates
       Sub-branch 1.3.6.1.4.1.19376.1.3.10.4 is dedicated to CDA Entry Level Templates
       Sub-branch 1.3.6.1.4.1.19376.1.3.10.9 is dedicated to CDA Template Fragments/Supporting Templates

Branch 1.3.6.1.4.1.19376.1.3.11 is dedicated to Value Sets newly defined by PaLM domain.

Branch 1.3.6.1.4.1.19376.1.8.9 is used to identify instances in the examples built by the AP domain.

Notes on other IHE OIDs used in the AP domain:

nn

5.2 Terminologies and controlled coded vocabularies

This section lists the terminologies and the coded vocabularies referenced by this Volume 3.

Table 5.2-1 Anatomic Pathology Terminologies and Coded Vocabularies

Could this be contributed by ArtDecor??? GH

codeSystem	codeSystemName	Description	Owner
2.16.840.1.113883.6.1	LOINC	Logical Observation Identifier Names and Codes	Regenstrief Institute
2.16.840.1.113883.6.96	SNOMED-CT	Systematized Nomenclature of Medicine – Clinical Terms	IHTSDO
1.3.6.1.4.1.19376.1.5.3.2	IHEActCode	Vocabulary defined by IHE PCC in PCC TF-2:5.1.2	IHE PCC
2.16.840.1.113883.6.3	ICD-10	International Classification of Diseases revision 10	WHO
2.16.840.1.113883.6.43	ICD-O-3	International Classification of Diseases for Oncology revision 3	WHO
	PubCan	A Public Database of Human Cancers http://www.pubcan.org	WHO
1.2.250.1.213.2.11	ADICAP Thesaurus	French thesaurus of lesions in anatomic pathology	ADICAP
1.2.250.1.213.2.12	SNOMED International (3.5)	Systematized Nomenclature of Medicine	ASIP santé
1.3.6.1.4.1.19376.1.8.2.1	PathLex	Temporary terminology covering the scope of anatomic pathology observation results and specimen collection procedure code	IHE-PAT
2.16.840.1.113883.15.6	TNM 7th edition	Internationally agreed-upon standards to describe and categorize cancer stages and progression http://www.uicc.org/resources/tnm	Union for International Cancer Control (UICC) & American Joint Committee on Cancer (AJCC)
2.16.840.1.113883.15.7	TNM 6th edition	Internationally agreed-upon standards to describe and categorize cancer stages and progression http://www.uicc.org/resources/tnm	Union for International Cancer Control (UICC) & American Joint Committee on Cancer (AJCC)
2.16.840.1.113883.15.8	TNM 5th edition	Internationally agreed-upon standards to describe and categorize cancer stages and progression http://www.uicc.org/resources/tnm	Union for International Cancer Control (UICC) & American Joint Committee on Cancer (AJCC)
1.2.276.0.76.3.1.131.1.5.1	DKG Coding Scheme	Internationally agreed-upon standards to describe and categorize cancer stages and progression, adapted for Germany	DKG (Deutsche Krebsgesellschaft)

5.3 Value Sets

The value sets defined or referenced by this Volume 3 of the IHE PaLM TF Suppl. are listed in Volume 4.

5.4 Namespaces

5.4.1 Namespace protecting extensions to the CDA schema

There is currently one single extension to the CDA.xsd schema used in PAT TF-3. This extension has been created by IHE LAB and is protected by this particular namespace in document instances: xmlns:lab="urn:oid:1.3.6.1.4.1.19376.1.3.2"

5.5 References to Content Modules built outside of IHE PAT TF

The Content Modules specified in this Volume 3 of the PAT TF leverage a number of Content Modules (currently CDA templates) produced and maintained by other groups, including other domains of IHE. Table 5.5-1 lists them.

Table 5.5-1 External Content Modules referenced by PAT TF-3

templateId	Standard	Definition	Source of Specification
1.3.6.1.4.1.19376.1.5.3.1.3.1	CDA R2	Reason for referral	IHE PCC TF-2:6.3.3.1.2
1.3.6.1.4.1.19376.1.5.3.1.3.4	CDA R2	History of present illness	IHE PCC TF-2:6.3.3.2.1
1.3.6.1.4.1.19376.1.5.3.1.3.6	CDA R2	Active Problems	IHE PCC TF-2:6.3.3.2.3
1.3.6.1.4.1.19376.1.5.3.1.4.2	CDA R2	Annotation Comment	IHE PCC TF-2:6.3.4.6
1.3.6.1.4.1.19376.1.3.3.1.7	CDA R2	Laboratory Performer	IHE PaLM TF-3:6.3.2.20
1.3.6.1.4.1.19376.1.3.3.1.6	CDA R2	Ordering Provider (ordering physician)	IHE PaLM TF-3:6.3.2.17
1.3.6.1.4.1.19376.1.3.3.1.4	CDA R2	Intended Recipient	IHE PaLM TF-3:6.3.2.14
1.3.6.1.4.1.19376.1.3.1.6	CDA R2	Laboratory Observation	IHE PaLM TF-3:6.3.4.13

5.6 IHE Codes for Anatomic Pathology Document Templates

Any AP structured report SHALL conform to the APSR generic Content Module Identified by templateId “1.3.6.1.4.1.19376.1.8.1.1.1” , and SHALL be associated with the following metadata:

typeCode = “11526-1”, which is the LOINC code for “Pathology study”.
formatCode = “urn:ihe:pat:apsr:all:2010”, with associated codingScheme = “1.3.6.1.4.1.19376.1.2.3” as assigned by the ITI Domain for codes used for the purposes of cross-enterprise document sharing (XDS).
The media type SHALL be “text/xml”.

6 Anatomic Pathology Content Modules

6.1 Conventions

In all Content Modules specified in this section, the abbreviation “AP” stands for “Anatomic Pathology”.

Various tables used in this section will further constrain the content. Within this volume, the following conventions are used:

M (R in v2)

A "Mandatory (Required in v2)" data element is one that shall always be provided. If there is information available, the data element must be present. If there is no information available, or it cannot be transmitted, the data element must contain a value indicating the reason for omission of the data.

R (R2 in v2)

A "Required (Required if data present in v2)" data element is one that shall be provided when a value exists. If the information cannot be transmitted, the data element shall contain a value indicating the reason for omission of the data. If no such information is available to the content creator or if such information is not available in a well identified manner (e.g., buried in a free form narrative that contains additional information relevant to other sections) or if the content creator requires that information be absent, the R2 section shall be entirely absent. The Content Creator application must be able to demonstrate that it can populate all required if known elements, unless it does not in fact gather that data. This “R2” code is the equivalent of the HL7 standard “RE” usage code. The value “R2” has been chosen in harmonization with the IHE PCC TF, which is the source of a large number of CDA R2 content modules.

O

An "Optional" data element is one that may be provided, irrespective of whether the information is available or not. If the implementation elects to support this optional section, then its support shall meet the requirement set forth for the "Required if data present" or R2.

C

A "Conditional" data element is one that is required, required if known or optional depending upon other conditions. These will have further notes explaining when the data element is required, et cetera.

6.2 HL7 CDA R2 Content Modules

6.2.1 Organization

6.2.1.1 Various Types of Content Modules

For the CDA Release 2.0 standard, the content modules are organized by:

document: The template for a whole document.

section: The template for a <section> element.

entry: The template for a <entry> element.

child element: An element of the CDA header or an element of a <section>, or an element nested at various depths below an <entry>, or an element appearing at some combination of these locations.

6.2.1.2 General constraints added by IHE PAT to a CDA R2 document

In the structured body of a CDA R2 document, a section has a narrative block (the text element), which presents the human-readable content of the section, and MAY have one entry or more. Sections MAY be nested within one another.

The content modules designed by the PAT TF bring or highlight the following constraints:

When a section has a text element and one or more entry element, the content coded for machine-processing in the entries SHALL be completely transcribed into human-readable content in the text element.

Conversely the text element MAY contain pieces of information, which are not available in machine-readable format in any entry element of the section.

For a document of the Anatomic Pathology domain, the entry elements are instantiated per specimen or per group of specimens observed together. One entry contains in machine-readable format observations of the section related to the same specimen or group of specimens. Beneath an entry, the observations are organized per problem.

The text element of the section is supposed to be also laid out per specimen or group of specimens and per problem observed.

The APSR Content Profile leaves the layout of the text element up to the Content Creator applications, or to further constraints brought by national extensions of this profile. However, given that the text element is usually composed of free text (e.g. dictated text), assembled with the text generated from the set of data, machine-encoded in the entry elements below, the Content Creator application MUST handle these two kinds of content, and provide a user interface, which avoids risks of overwriting text automatically derived from the entries with free text typed in by the user (e.g., using forms with dedicated free text areas and distinct protected areas for text generated out of structured data).

Information that is sent SHALL clearly identify distinctions between:

None

It is known with complete confidence that there are none. This indicates that the sender knows that there is no relevant information of this kind that can be sent.

None Known

None known at this time, but it is not known with complete confidence that none exist.

Asked but unknown

The information was requested but could not be obtained. Used mainly in the context where an observation was made but the result could not be determined.

Unknown

The information is not known, or is otherwise unavailable.

Other, not specified

The actual value does not belong to the assigned value set and is not reported at all by the author.

Other, specify

The actual value does not belong to the assigned value set and the author of the report provides this foreign value anyway.

Not applicable

No proper value is applicable in this context.

Sections that are required to be present but have no information should use one of the above phrases where appropriate in the text element.

Structural elements that are required but have no information shall provide a “nullFlavor” attribute coding the reason why the information is missing.

Situation	nullFlavor	HL7 Definition
Asked but unknown	ASKU	Information was sought but not found
Unknown	UNK	A proper value is applicable, but not known
Other, not specified	OTH	The actual value is not an element in the value domain of a variable. (e.g., concept not provided by required code system).
Not applicable	NA	No proper value is applicable in this context
Temporarily not available	NAV	Information is not available at this time but it is expected that it will be available later.

The two situations “None” and “None known” represent effective values, which are part of the related value sets.

The situation “Other, specify” can be handled in two ways in a coded data element:

Leaving empty the code attribute and providing the non-coded answer in the originalText attribute.
Providing a value coded from a different coding scheme, when the coding strength of the element is “CWE” (coded with extensions). The attributes code, displayName, codeSystem and codeSystemName then describe the foreign code.

For ancillary techniques, the situation “ not performed” or “none performed” is represented by nullFlavor = NAV.

6.2.1.3 Common structure for CDA APSR

Figure 6.2.1.3-1 summarizes the common structure of the first five CDA APSR Section Content Modules specified here. Regarding the machine-readable part, the figure highlights the organization of entries within a section and of observations within an entry. Specific details such as the structure of sub-sections are not shown on this global picture.

Figure 6.2.1.3-1 CDA APSR: common structure of machine-readable content for CDA APSR Section Content Modules except Procedure Step Content Module

Note 1: In order to facilitate a further de-identification process of CDA AP reports for some secondary use (biosurveillance, epidemiology…) the producer of an APSR SHOULD avoid populating any patient identification data (name, sex, birthdate, address …) into the body of the report (neither <entry> elements nor <text> elements). The appropriate location for patient identification data is the CDA header exclusively.

Note 2: The AP sections are those shown on figure 10.4.1-1 of Volume 1.

Note 3: The possible sub sections are shown on figure 10.4.1-1 of Volume 1.

Figure 6.2.1.3-2 shows the common structure of the Procedure Step Content Module specified here, too.

Figure 6.2.1.3-2 CDA APSR: common structure of machine-readable content for Procedure Step Content Module

6.2.2 Common layout for the specification of a CDA Content Module

Each CDA R2 Content Module specified in this Volume is presented with this layout:

6.2.2.1 Content Module Name – OID

Each Content Module is uniquely identified by a unique OID.

6.2.2.1.1 Definition and purpose

This section presents the content module and its purpose.

In case this module is a specialization of a more generic one, the section references its parent template.

6.2.2.1.2 Specification and example

The both separate chapters from reference text are summarized her as one single paragraph due to the Art-Decor construction. GH

This section consists of a transclusion of an Art-Decor APSR 2.0 template for the content module, delivering a snippet, showing an example of the content module.

The form of the specification depends upon the kind of CDA Content Module (document, section, entry, header and/or entry element). It respects the guidelines below:

The specification provides a table describing the structure of the content module, each element being located through an XPATH expression combined with indentation. The table provides cardinalities, meaning for each elements, references value sets described in section 5 for attributes, and provides the mapping with HL7 V2.5.1 relevant fields. The table also points the content modules nested in the current one, by showing their templateId, and locating their specification in the current PAT TF-3 or in the IHE TF they belong to (PCC, LAB, etc.).
The table is simplified for section content modules: It only lists the content modules nested in the section template.
Below the tables appear notes providing additional information and detailing particular constraints on some elements or attributes.

6.2.3 CDA R2 Document Content Modules

6.2.3.1 AP Structured Report (APSR) - 1.3.6.1.4.1.19376.1.8.1.1.1

6.2.3.1.1 Definition and purpose

This Document Content Module defines the base set of constraints that apply to all AP structured report, related to any kind of lesion or diagnostic. In other words, this is the generic template for any AP structured report.

The body of this Document Content Module has the hierarchy of sections and entries depicted by figure 4.1.2.1-1 in Volume 1.

6.2.3.1.2 Specification and Example

Id 1.3.6.1.4.1.19376.1.8.1.1.1 Effective Date valid from 2014‑05‑13 11:57:57

Status Draft Version Label 2.0

Name AnatomicPathologyStructuredReportContentModule Display Name Anatomic Pathology Structured Report Content Module

Description

Anatomic Pathology Structured Report Content Module.

This document content module represents the generic set of constraints applied to any structured report for surgical pathology in all fields of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as for Cytopathology.

The body of this Document Content Module specifies a common hierarchy of sections and entries depicted by figure 10.4.1-1 in Volume 1 IHE_PaLM_Suppl_APSR 2.0. The only mandatory section is the Diagnostic Conclusion Section. And the only mandatory entry is the Problem Organizer Entry below this section.

Context Pathname /

Label PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

Classification CDA Document Level Template

Open/Closed Open (other than defined elements are allowed)

Used by / Uses

Used by 0 transactions and 0 templates, Uses 20 templates

Uses	as	Name	Version
1.3.6.1.4.1.19376.1.3.3.1.1	Include	Human Patient (2017)	2017‑06‑07
1.3.6.1.4.1.19376.1.8.1.4.2	Include	CDA author IHE	2016‑06‑21 14:02:11
2.16.840.1.113883.10.12.103	Include	CDA dataEnterer	2005‑09‑07
1.3.6.1.4.1.19376.1.8.1.4.6	Containment	CDA Informant(Header&Body) APSR2 (2.0)	2016‑07‑08 11:22:58
2.16.840.1.113883.10.12.104	Include	CDA custodian	2005‑09‑07
1.3.6.1.4.1.19376.1.3.3.1.4	Include	XD-LAB Information Recipient (2017)	2008‑08‑08
1.3.6.1.4.1.19376.1.3.10.2.4	Include	XD-LAB LegalAuthenticator (2017)	2016‑07‑05
1.3.6.1.4.1.19376.1.8.1.4.3	Include	CDA authenticator IHE	2016‑07‑09 15:03:59
1.3.6.1.4.1.19376.1.3.3.1.6	Include	Ordering Provider (2017)	2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.1	Include	CDA Participant Specimen Collector	2016‑06‑13 14:21:13
1.3.6.1.4.1.19376.1.3.10.2.5	Include	CDA Participant Pertinent Insurance Information	2017‑11‑13 16:52:30
1.3.6.1.4.1.19376.1.3.3.1.7	Containment	Laboratory Performer (2017)	2008‑08‑08
2.16.840.1.113883.10.12.113	Include	CDA componentOf	2005‑09‑07
1.3.6.1.4.1.19376.1.8.1.2.1	Containment	Clinical Information Section (2.0)	2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2	Containment	Intraoperative Observation Section (2.0)	2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3	Containment	Macroscopic Observation Section (2.0)	2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4	Containment	Microscopic Observation Section (2.0)	2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.3.10.3.1	Containment	Additional Specified Observation Section (2.0)	2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.2.5	Containment	Diagnostic Conclusion Section (2.0)	2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.2.6	Containment	Procedure Steps Section (2.0)	2014‑05‑13 19:33:12

Relationship Specialization: template 2.16.840.1.113883.10.12.1 (2005‑09‑07)

Example

example for use case #1

<ClinicalDocument xsi:schemaLocation="urn:hl7-org:v3 infrastructure/cda/CDA_extended.xsd"> <realmCode code="UV"/> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root="1.3.6.1.4.1.19376.1.8.1.1.1"/> <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_1" assigningAuthorityName="IHE PaLM Technical Committee"/> <code code="60568-3" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology Synoptic report"/> <title>Anatomic Pathology Structured Report - Breast Biopsy</title> <effectiveTime value="201001041605-0500"/> <confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="en-US"/> <setId root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008" assigningAuthorityName="IHE PaLM Technical Committee"/> <versionNumber value="1"/>  <recordTarget> <patientRole> <id extension="0411886319605719371016" root="1.3.6.1.4.1.19376.1.8.9.2"/> <addr use="HP"> <streetAddressLine>39 East Street</streetAddressLine> <postalCode>69499</postalCode> <city>Appleton</city> <state>WI</state> <country>United States</country> </addr> <telecom nullFlavor="NASK"/> <patient> <name> <prefix>Miss</prefix> <given>EVE</given> <family qualifier="BR">ONEWOMAN</family> </name> <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/> <birthTime value="19710921"/> </patient> </patientRole> </recordTarget>  <author> <templateId root="1.3.6.1.4.1.19376.1.8.1.4.2"/> <time value="20100104131933-0500"/> <assignedAuthor> <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/> <addr nullFlavor="MSK"/> <telecom value="tel:+33-602030499"/> <assignedPerson> <name> <given>Marcel</given> <family>Pathologist</family> <suffix>Ph D</suffix> </name> </assignedPerson> <representedOrganization> <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/> <name>CANCER INSTITUTE</name> <telecom nullFlavor="MSK"/> <addr nullFlavor="MSK"/> </representedOrganization> </assignedAuthor> </author>  <dataEnterer> <time value="20100104131720-0500"/> <assignedEntity> <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="A32"/> <addr nullFlavor="MSK"/> <telecom nullFlavor="MSK"/> <assignedPerson> <name> <given>Adeline</given> <family>Medsecret</family> </name> </assignedPerson> </assignedEntity> </dataEnterer> <informant>  </informant>  <custodian> <assignedCustodian> <representedCustodianOrganization> <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/> <name>CANCER INSTITUTE</name> <telecom use="PUB" value="0466666666"/> <addr> <streetAddressLine>38 Cramberry Street</streetAddressLine> <postalCode>69499</postalCode> <city>Appleton</city> <state>WI</state> </addr> </representedCustodianOrganization> </assignedCustodian> </custodian>  <informationRecipient> <templateId root="1.3.6.1.4.1.19376.1.3.3.1.4"/> <intendedRecipient> <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="987"/> <addr> <streetAddressLine>1600 Clifton Road</streetAddressLine> <city>Atlanta</city> <state>GA</state> <postalCode>30333</postalCode> </addr> <telecom value="tel:404-639-3535"/> <informationRecipient> <name> <family>WOULDLIKETOKNOW</family> <given>Thomas</given> </name> </informationRecipient> </intendedRecipient> </informationRecipient>  <legalAuthenticator> <time value="20100104152503-0500"/> <signatureCode code="S"/> <assignedEntity> <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/> <assignedPerson> <name> <given>Marcel</given> <family>Pathologist</family> </name> </assignedPerson> </assignedEntity> </legalAuthenticator>  <authenticator> <templateId root="1.3.6.1.4.1.19376.1.8.1.4.3"/> <time value="20100104142503-0500"/> <signatureCode code="S"/> <assignedEntity> <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567898"/> <addr nullFlavor="MSK"/> <telecom nullFlavor="MSK"/> <assignedPerson> <name> <given>Jonas</given> <family>Jones</family> <prefix>MD</prefix> </name> </assignedPerson> </assignedEntity> </authenticator>  <participant typeCode="REF"> <templateId root="1.3.6.1.4.1.19376.1.3.3.1.6"/> <time> <high value="20091231"/> </time> <associatedEntity classCode="PROV"> <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567892"/> <addr nullFlavor="NASK"/> <telecom value="tel:0147150000" use="EC"/> <associatedPerson> <name> <prefix>Doctor</prefix> <given>Eva</given> <family>Surgeon</family> <suffix>Ph D</suffix> </name> </associatedPerson> </associatedEntity> </participant>    <inFulfillmentOf> <order> <id root="1.3.6.1.4.1.19376.1.8.9.8" extension="12345"/> </order> </inFulfillmentOf>  <documentationOf> <serviceEvent> <id root="1.3.6.1.4.1.19376.1.8.9.9" extension="A7102400008"/> <code code="371528001" displayName="Pathology report (record artifact)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/> <lab:statusCode code="completed"/> <effectiveTime>  <low value="200912300922-0500"/>  <high value="201001041605-0500"/> </effectiveTime>  <performer typeCode="PRF"> <templateId root="1.3.6.1.4.1.19376.1.3.3.1.7"/> <time> <high value="201001041605-0500"/> </time> <assignedEntity> <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/> <representedOrganization> <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/> <name>CANCER INSTITUTE</name> <telecom nullFlavor="MSK"/> <addr nullFlavor="MSK"/> </representedOrganization> </assignedEntity> </performer> </serviceEvent> </documentationOf>   <componentOf> <encompassingEncounter> <id root="1.3.6.1.4.1.19376.1.8.9.7" extension="234567890"/> <code code="ACUTE" displayName="inpatient acute"/> <effectiveTime> <high value="2201001040735-0500"/> </effectiveTime> <location typeCode="LOC"> <healthCareFacility classCode="SDLOC"> <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="11223344"/> <serviceProviderOrganization classCode="ORG" determinerCode="INSTANCE"> <name>Surgery theater</name> <asOrganizationPartOf> <wholeOrganization> <name>CANCER INSTITUTE</name> </wholeOrganization> </asOrganizationPartOf> </serviceProviderOrganization> </healthCareFacility> </location> </encompassingEncounter> </componentOf>  <component typeCode="COMP" contextConductionInd="true"> <structuredBody classCode="DOCBODY" moodCode="EVN"> <component typeCode="COMP" contextConductionInd="true">  </component> <component typeCode="COMP" contextConductionInd="true">  </component> <component typeCode="COMP" contextConductionInd="true">  </component> <component typeCode="COMP" contextConductionInd="true">  </component> <component typeCode="COMP" contextConductionInd="true">  </component> <component typeCode="COMP" contextConductionInd="true">  </component> <component typeCode="COMP" contextConductionInd="true">  </component> </structuredBody> </component></ClinicalDocument>

Item DT Card Conf Description Label

hl7:ClinicalDocument

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@classCode

cs

1 … 1

F

DOCCLIN

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

This element is identifying the set of constraints applied to the CDA R2 standard by this IHE specification of a AP report. The following templateId SHALL be present and valued as follows to indicate compliance with the APSR 2.0 content module specification.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.8.1.1.1

hl7:realmCode

CS (extensible)

1 … 1

M

This element SHALL be present and is valued from the RealmOfUse [2.16.840.1.113883.1.11.11050] subset, within the VocabularyDomainQualifier value set. In the international context of this profile used as it is without any further extension, the realm code SHALL be <realmCode code="UV"/> (universal).

Whenever a national extension has been defined and is used, the realm code SHALL identify this national extension.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:typeId

II

1 … 1

M

This element is a technology-neutral explicit reference to the standard CDA R2. It SHALL be present and valued as follows:
ClinicalDocument/typeId@root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models);
ClinicalDocument.typeId@extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description).

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@root

uid

1 … 1

F

2.16.840.1.113883.1.3

@extension

st

1 … 1

F

POCD_HD000040

hl7:id

II

1 … 1

M

ClinicalDocument/Id SHALL be present. It represents the unique instance identifier of the clinical document. The combination of the root and extension attributes SHALL provide a globally unique identifier, in accordance with CDA R2, without further constraints.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@root

uid

1 … 1

R

Here the OID for PAT exemplary instances, in practice the OID of the LIS

@extension

st

1 … 1

R

Here a hypothetical document ID, most often derived from the accession number

Constraint

A report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report.

The unique id of the current revision of the report is carried by the id element, and is composed of

id@root, which SHALL be an OID,
and optionally id@extension, which can be any string so that the concatenation of the two attributes root and extension provide a globally unique id, which identifies this release of the report.

Example

Report ID from use case #1

<id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_1" assigningAuthorityName="IHE PaLM Technical Committee"/>

hl7:code

CE (required)

1 … 1

M

ClinicalDocument/code SHALL be present. The document type of this content module is always
<code code="60568-3"
codeSystem="2.16.840.1.113883.6.1"
displayName="Pathology Synoptic report"
codeSystemName="LOINC"/>

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@code

CONF

1 … 1

F

60568-3

@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 Synoptic report

hl7:title

ST

1 … 1

M

The APSR <title> SHALL be present. It is the local translation of the code@displayName.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

CONF

element content shall be "Anatomic Pathology Structured Report"

Example

Report title from use case #1

<title>ANATOMIC PATHOLOGY REPORT - BREAST BIOPSY</title>

hl7:effectiveTime

TS

1 … 1

M

ClinicalDocument/effectiveTime SHALL be present. It contains the creation date & time of the laboratory report as an electronic document. In case this is a new revision replacing a previous version (identified in parentDocument), this is the date & time of the new revision.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:confidentialityCode

CE (required)

1 … 1

M

ClinicalDocument/confidentialityCode SHALL be present in accordance with the HL7 CDA R2 standard.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (2014‑06‑09)

hl7:languageCode

CS (required)

1 … 1

M

ClinicalDocument/languageCode SHALL be present in accordance with the HL7 CDA R2 standard.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (2014‑03‑26)

hl7:setId

II

1 … 1

M

ClinicalDocument/setId SHALL be present to enable further updates of the clinical document. It is an identifier that is common across all revisions of this AP report.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@root

uid

1 … 1

R

@extension

st

1 … 1

R

Constraint A report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report.
The setId element provides a globally unique identifier that is common across all successive revisions of the report. This identifier is similarly composed of setId@root, which SHALL be an OID, and optionally setId@extension.

Example

Report set ID from use case #1

<id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008" assigningAuthorityName="IHE PaLM Technical Committee"/>

hl7:versionNumber

INT

0 … 1

R

ClinicalDocument/versionNumber MAY be present. As requested by the CDA standard, it is an integer value used as versioning.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@value

int

1 … 1

R

Constraint

A report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report.

The version number of the current revision of the report is a positive integer (1, 2 …) provided in the versionNumber element.

Example

Report version number for use case #1

<versionNumber value="1"/>

Included

1 … 1

M

from 1.3.6.1.4.1.19376.1.3.3.1.1 Human Patient (2017‑06‑07)
The Patient.

The anatomic pathology report is related to ONE SINGLE patient.

A patient SHALL be identified with at least one unique patientRole/Id.
The patient address and telecom SHALL be provided (or null flavored).
The patient identity SHALL provide AT LEASTthe patient full name, sex and date/time of birth.

hl7:recordTarget

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:patientRole

1 … 1

R

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:id

II

1 … *

R

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:addr

AD

1 … *

All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:telecom

TEL

1 … *

All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:patient

1 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:id

II

0 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:name

PN

1 … *

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:administrativeGenderCode

CE

1 … 1

R

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:birthTime

TS

1 … 1

R

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

Included

1 … *

M

from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
The Author Content Module represents an author of the report. This element is repeatable. The sub-element author/time carries the date/time of the authoring action.

   
       
At least one ClinicalDocument/author SHALL be present with a time in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. The author/time element carries the date&time the AP report was produced. The AP report can be authored by a software system or by a person or by both.

Source: PaLM Suppl.APSR 2.0‑3: 6.3.6.2

hl7:author

1 … *

M

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:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

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

@determinerCode

0 … 1

F

INSTANCE

hl7:name

PN

0 … *

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

hl7:assignedAuthoringDevice

0 … 1

C

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:manufacturerModelName

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:representedOrganization

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

@determinerCode

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

@determinerCode

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

Included 0 … * R from 2.16.840.1.113883.10.12.103 CDA dataEnterer (2005‑09‑07)
Transcriptionist

hl7:dataEnterer

0 … *

R

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@typeCode

0 … 1

F

ENT

@contextControlCode

0 … 1

F

OP

hl7:time

TS

0 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:assignedEntity

1 … 1

Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:informant

0 … *

R

Zero or more informant MAY be mentioned in the header of the report. An informant is either an assignedEntity (a professional participating to the healthcare process, and who was assigned a defined role in that process) or a relatedEntity (a person who knows the patient and has provided relevant information concerning the patient). Hence the condition is either assignedEntity is present or relatedEntity is present. These two elements are defined in the content module “Informant”.

Source: PaLM 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 (2016‑07‑08 11:22:58)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.6']]

Included 1 … 1 M from 2.16.840.1.113883.10.12.104 CDA custodian (2005‑09‑07)
ClinicalDocument/custodian SHALL be present with an id in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. It represents the organization that is in charge of maintaining the AP report.

hl7:custodian

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@typeCode

0 … 1

F

CST

hl7:assignedCustodian

1 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@classCode

0 … 1

F

ASSIGNED

hl7:representedCustodianOrganization

1 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@classCode

0 … 1

F

ORG

@determinerCode

0 … 1

F

INSTANCE

hl7:id

II

1 … *

M

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:name

ON

0 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:telecom

TEL

0 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:addr

AD

0 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

Included

0 … *

R

from 1.3.6.1.4.1.19376.1.3.3.1.4 XD-LAB Information Recipient (2008‑08‑08)
The Intended Recipient Content Module represents a healthcare provider,

other than the ordering physician, expecting to receive a copy of the report. This repeatable element informationRecipient of the CDA header is used to list the intended recipients who were known at the time the report was created and issued.

Source: PaLM TF-3: 6.3.2.14

hl7:informationRecipient

0 … *

R

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:templateId

II

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.3.3.1.4

hl7:intendedRecipient

1 … 1

R

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:id

II

0 … *

R

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:addr

AD

1 … *

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:telecom

TEL

1 … *

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:informationRecipient

0 … 1

Contains 1.3.6.1.4.1.19376.1.3.10.9.18 PlayingEntity or person with Name (DYNAMIC)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:receivedOrganization

0 … 1

Contains 1.3.6.1.4.1.19376.1.3.10.9.13 Organization with Name, Addr, Telecom (DYNAMIC)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

Included

1 … 1

M

from 1.3.6.1.4.1.19376.1.3.10.2.4 XD-LAB LegalAuthenticator (2016‑07‑05)
The Legal authenticator Content Module describes a pathologist having verified the content of the report, using the element legalAuthenticator.

The report SHALL have one legal Authenticator

Source: PaLM TF-3: 6.3.2.15

hl7:legalAuthenticator

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:time

TS

1 … 1

R

The sub-element time carries the date&time this legal authentication took place.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:signatureCode

CS

1 … 1

R

The sub-element signatureCode carries the “signed” (S) status

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@code

CONF

0 … 1

F

S

hl7:assignedEntity

1 … 1

R

All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:addr

AD

1 … *

R

Constrained by this specification to require the presence of name, addr and telecom.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:telecom

TEL

1 … *

R

Constrained by this specification to require the presence of name, addr and telecom.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:assignedPerson

0 … 1

All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.

Contains 1.3.6.1.4.1.19376.1.3.10.9.18 PlayingEntity or person with Name (DYNAMIC)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:representedOrganization

0 … 1

All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.

Contains 1.3.6.1.4.1.19376.1.3.10.9.13 Organization with Name, Addr, Telecom (DYNAMIC)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

Included

0 … *

R

from 1.3.6.1.4.1.19376.1.8.1.4.3 CDA authenticator IHE (2016‑07‑09 15:03:59)

The Content validator Content Module describes a pathologist having verified the content of the report, using the element authenticator. This element authenticator is used when the pathologist having verified the content of the report is distinct from the pathologist assuming the legal responsibility for this report, described in the legalAuthenticator element.

The report MAY have zero or more Content Validators.

Source: PaLM Suppl. APSR 2.0-3: 6.3.6.3

hl7:authenticator

0 … *

R

PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator

@typeCode

cs

1 … 1

F

AUTHEN

hl7:templateId

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.8.1.4.3

hl7:time

TS

1 … 1

R

Time of validation

PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator

hl7:assignedEntity

0 … 1

C

AssignedPerson SHALL be given with name, representedOrganization MAY be given.
Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (2005‑09‑07)

PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator

Included

1 … 1

R

from 1.3.6.1.4.1.19376.1.3.3.1.6 Ordering Provider (2008‑08‑08)

   The Ordering Provider Content Module represents the physician who has submitted the specimen examination order to the anatomic pathology laboratory. As specified in PaLM TF-3, this physician is represented in the CDA header as a participant element with the typeCode attribute valued “REF”. The sub-element participant/time carries the date/time of issuance of the
           order.

   
Source: PaLM TF-3: 6.3.2.17

hl7:participant

1 … 1

R

Referral Ordering Physician

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@typeCode

cs

1 … 1

F

REF

hl7:templateId

II

1 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.3.3.1.6

hl7:time

IVL_TS

1 … 1

R

This element represents the date and time the order was placed. Time MAY be present.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:associatedEntity

1 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:addr

AD

1 … *

R

The address of this person (referral ordering physician) SHALL be present.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:telecom

TEL.AT

1 … *

R

The telecom of this person (referral ordering physician) SHALL be present.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

Schematron assert role error

test not(hl7:assignedPerson) or hl7:assignedPerson/hl7:name

Message The <name> sub-element SHALL be present when <assignedPerson> present.

hl7:associatedPerson

0 … 1

R

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:scopingOrganization

0 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

Included

0 … *

R

from 1.3.6.1.4.1.19376.1.8.1.4.1 CDA Participant Specimen Collector (2016‑06‑13 14:21:13)
The Specimen Collector Content Module is only used in case a specimen

provided as input to the AP act documented in this report, was collected by a different party than the ordering physician. In that case, this specimen collector is represented in the CDA header as a participant element with the typeCode attribute valued “DIST” and the sub-element participant/time carries the time period of the specimen collection.

Source: PAT TF-3: 6.2.6.1

hl7:participant

0 … *

R

The Specimen Collector Content Module is only used in case a specimen provided as input to the AP act documented in this report, was collected by a different party than the ordering physician. In that case, this specimen collector is represented in the CDA header as a participant element with the typeCode attribute valued “DIST” and the sub-element participant/time carries the time period of the specimen collection.

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

@typeCode

cs

1 … 1

F

DIST

hl7:templateID

II

1 … 1

M

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.8.1.4.1

hl7:time

IVL_TS

1 … 1

M

Specimen collection time

The specimen collection time is an interval, which may be reduced to a point in time (see usage of data type IVL_TS).

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

hl7:associatedEntity

0 … 1

R

At least one of the two elements

associatedPerson and scopingOrganization must be present. Both may be present.

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

@classCode

cs

1 … 1

F

PROV

hl7:id

II

1 … *

R

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

hl7:addr

AD

1 … *

R

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

hl7:telecom

TEL.AT

1 … *

R

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

hl7:associatedPerson

0 … *

C

Person who collected the specimen.
Only full name(s) SHALL be given.
Contains 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

hl7:scopingOrganization

0 … 1

C

Organization taking care for specimen collection.
Identifiers, name, telecom, and address SHOULD be given.
Contains 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

Included 0 … 1 R from 1.3.6.1.4.1.19376.1.3.10.2.5 CDA Participant Pertinent Insurance Information (2017‑11‑13 16:52:30)
Key insurance information of the patient

hl7:participant

0 … 1

R

Insurance information of the patient in context for reporting to cancer registries (in Germany)

PaLM Suppl. 2.0‑3:6.3.6.13

@typeCode

cs

1 … 1

F

HLD

hl7:templateId

II

1 … *

M

PaLM Suppl. 2.0‑3:6.3.6.13

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.3.10.2.5

hl7:time

IVL_TS

0 … 1

R

time shows the end of the current insurance period, e.g. end of the quartal

PaLM Suppl. 2.0‑3:6.3.6.13

Example <time> <high value="20171231"/></time>

hl7:associatedEntity

1 … 1

M

Data of the insured person

PaLM Suppl. 2.0‑3:6.3.6.13

@classCode

cs

1 … 1

F

POLHOLD

hl7:id

II

0 … *

R

ID(s) of the insured person (patient), e.g. ID of the insured, ID of the health card, etc.

PaLM Suppl. 2.0‑3:6.3.6.13

hl7:code

CE

0 … 1

R

status of the insured person

PaLM Suppl. 2.0‑3:6.3.6.13

@codeSystem

CONF

0 … 1

F

2.16.840.1.113883.5.111 (Role Code)

Example <code code="SELF" codeSystem="2.16.840.1.113883.5.111" displayName="self"> <translation code="1" codeSystem="2.16.840.1.113883.3.7.1.1" displayName="member"/></code>

hl7:translation

CV

0 … 1

R

further codes of the status of the insured person,

e.g. for Germany from value set S_KBV_VERSICHERTENSTATUS

1.2.276.0.76.11.162

PaLM Suppl. 2.0‑3:6.3.6.13

hl7:addr

AD

0 … 1

R

PaLM Suppl. 2.0‑3:6.3.6.13

hl7:telecom

TEL

0 … *

R

PaLM Suppl. 2.0‑3:6.3.6.13

hl7:associatedPerson

0 … 1

R

Data of the insured person, which may be different from the patient.
Contains 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)

PaLM Suppl. 2.0‑3:6.3.6.13

hl7:scopingOrganization

1 … 1

R

Data of the Insurance company, including the ID, the address data and the name.
In Germany the ID is formed by the ID itself (@extension = so-called IKNR) and the OID for IKNR (@root="1.2.276.0.76.4.5") in Germany.
Contains 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)

PaLM Suppl. 2.0‑3:6.3.6.13

hl7:inFulfillmentOf

0 … 1

R

The inFulfillmentOf/order element MAY be present. It represents the Placer Order or the Placer Group that was fulfilled, the Id of which is carried by inFulfillmentOf/order/id.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@typeCode

cs

1 … 1

F

FLFS

hl7:order

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@classCode

cs

1 … 1

F

ACT

@moodCode

cs

1 … 1

F

RQO

hl7:id

II

1 … *

R

Placer order group ID or Placer order ID

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:documentationOf

1 … 1

M

Documented act.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@typeCode

cs

1 … 1

F

DOC

hl7:serviceEvent

1 … 1

M

The AP report is documenting a service (documentationOf/serviceEvent) performed by a surgical pathology laboratory. The Laboratory Performer Content Module represents this laboratory, and is fully described in the sub-element

documentationOf/serviceEvent/performer.
In case more than one laboratory contributed to a service, only the primary laboratory is in the CDA header, attached to the serviceEvent element, and the other (secondary) laboratories are described only in the sections of the report that they contributed to, in the body of the report.

Source: PaLM TF3: 6.3.2.19

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@classCode

cs

1 … 1

R

@moodCode

cs

1 … 1

R

hl7:id

II

1 … *

M

ID of the Act, i.e. Accession number

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:code

CE (extensible)

0 … 1

R

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

CONF

@code shall be "PATREPE"

@codeSystem shall be "2.16.840.1.113883.5.4"

@codeSystemName shall be "HL7 ActCode"

@displayName shall be "pathology report entry task"

or

@code shall be "371528001"

@codeSystem shall be "2.16.840.1.113883.6.96"

@codeSystemName shall be "SCT"

@displayName shall be "Pathology report (record artifact)"

hl7:effectiveTime

IVL_TS

0 … 1

R

Use of sub element documentationOf/serviceEvent/effectiveTime to document the time boundaries of events in the document is appropriate.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

ihe-lab:statusCode

CS (required)

0 … 1

R

   The statusCode below documentationOf/serviceEvent is an extension to the CDA R2 standard, added by PaLM TF-3 to distinguish a preliminary report (statusCode@code="active") from a final report (statusCode@code="completed"). 
The statusCode sub element is  further described in section A.3 of PaLM TF-3. This sub-element is required. When it is not there, the documented Act is assumed to be completed and the report is assumed to be a final report.

This extension to the standard is protected by a dedicated namespace associated in the ClinicalDocument element to the prefix lab:

<Clinical Document xmlns:lab="urn:oid:1.3.6.1.4.1.19376.1.3.2" … >

Source: PaLM TF3: 6.3.2.19

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

Constraint The statusCode@code="completed" is only applicable, if ALL content modules of the Clinical Document have the statusCode@code="completed", too, or have the statusCode@code="aborted".

CONF

The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.4 ActStatusActiveCompleted (2008‑08‑08)

Schematron assert role error

test hl7:serviceEvent/lab:statusCode[@code='completed']

Message Status code of all Content Modules SHALL be "complete" or "aborted"

hl7:performer

0 … *

R

Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.3.1.7']]

hl7:relatedDocument

0 … 1

R

ClinicalDocument/relatedDocument/parentDocument

This element SHALL be present in case of an update replacement of a previous report. In this case relatedDocument@typeCode attribute SHALL be valued "RPLC", the new report replacing the parent one.

Note 1: A non-final AP structured report published in an XDS infrastructure will likely be replaced afterwards by the final report. When this event occurs, the Content Creator Actor SHALL apply the following rules:

ClinicalDocument/setId SHALL have the same value in the new report as in the replaced report.
ClinicalDocument/versionNumber SHALL be incremented in the replacing report (i.e., the final one).
ClinicalDocument/relatedDocument@typeCode attribute SHALL be valued ”RPLC”
ClinicalDocument/relatedDocument/parentDocument/id in the new report SHALL be equal to ClinicalDocument/ id of the replaced document.

The Document Source Actor SHALL apply the following rules on XDSDocumentEntry metadata:

The final report SHALL be associated with the previously published one, using RPLC relationship and the previous report SHALL be “Deprecated” as described in ITI TF-2:4.1.6.1.

Note 2: A non-final report can also be replaced by a more recent, albeit still non-final report. The rules above also apply in this case.

Note 3: A final report can also be replaced by a corrective final report. The rules above also apply in this case.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@typeCode

cs

1 … 1

F

RPLC

relatedDocument@typeCode attribute SHALL be valued "RPLC"

hl7:parentDocument

ANY

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:id

II

1 … 1

M

SHALL be equal to ClinicalDocument/ id of the replaced document.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:setId

II

1 … 1

M

SHALL have the same value in the new report as in the replaced report.

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:versionNumber

INT

0 … 1

R

SHALL have the same value as in the replaced report (when provided there).

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

Included

0 … 1

R

from 2.16.840.1.113883.10.12.113 CDA componentOf (2005‑09‑07)
The ClinicalDocument/componentOf/encompassingEncounter element MAY be present.

It describes the encounter during which the reported AP observations were ordered. When present the encounter SHALL:

be identified with an id element: encompassingEncounter/id
The encounter SHALL have an effective time that represents the time interval (possibly still running, e.g., an inpatient current stay) of the encounter or a point in time at which the encounter took place (e.g., an outpatient consultation): encompassingEncounter/ effectiveTime

The encounter MAY provide any number of encounter participants (encompassingEncounter/encounterParticipant/assignedEntity). When present, encounter participants SHALL be in accordance with the HL7 CDA R2 standard with a time and further constrained by this specification to require the presence of name, addr and telecom. Additionally, the encounter participant SHALL have a typeCode with one the values selected from the x_EncounterParticipant domain: The encounter MAY precise the patient location during this encounter. This is the healthcare facility in which the patient was located when the reported AP observations were ordered: encompassingEncounter/location/healthCareFacility. This healthcare facility can be represented as a physical place (e.g., room, floor, building, office) or as an organization (e.g., service, department, team) or both: healthCareFacility/location, healthCareFacility/serviceProviderOrganization.

hl7:componentOf

0 … 1

R

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@typeCode

0 … 1

F

COMP

hl7:encompassingEncounter

1 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@classCode

0 … 1

F

ENC

@moodCode

0 … 1

F

EVN

hl7:id

II

0 … *

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:code

CE

0 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC)

hl7:effectiveTime

IVL_TS

1 … 1

R

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:dischargeDispositionCode

CE

0 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

CONF

shall be drawn from concept domain "EncounterDischargeDisposition"

hl7:responsibleParty

0 … 1

Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@typeCode

0 … 1

F

RESP

hl7:encounterParticipant

0 … *

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@typeCode

cs

1 … 1

R

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC)

hl7:time

IVL_TS

0 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:assignedEntity

1 … 1

Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:location

0 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@typeCode

0 … 1

F

LOC

hl7:healthCareFacility

1 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@classCode

0 … 1

F

SDLOC

hl7:id

II

0 … *

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:code

CE

0 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC)

hl7:location

0 … 1

Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:serviceProviderOrganization

0 … 1

Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

hl7:component

1 … 1

R

Body of the CDA Clinical document

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

bl

1 … 1

F

true

hl7:structuredBody

1 … 1

R

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

@classCode

cs

1 … 1

F

DOCBODY

@moodCode

cs

1 … 1

F

EVN

hl7:component

0 … 1

R

The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, clinical laboratory data, specimen(s) description, collection procedure, reason for anatomic pathology procedure.
Contains 1.3.6.1.4.1.19376.1.8.1.2.1 Clinical Information Section (2014‑05‑13 14:38:08)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

where [@typeCode='COMP'] [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.2.1']]]

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

bl

1 … 1

F

true

hl7:component

0 … 1

R

Contains 1.3.6.1.4.1.19376.1.8.1.2.2 Intraoperative Observation Section (2014‑05‑13 19:29:16)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

where [@typeCode='COMP'] [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.2.2']]]

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

bl

1 … 1

F

true

hl7:component

0 … 1

R

The Macroscopic Observation section contains the description of the specimen received or obtained by the laboratory (specimen type and state), the gross observation, links to gross images, if taken, processing information and tissue disposition (representative sampling and tissue submitted for additional studies or sent to biorepository.
Contains 1.3.6.1.4.1.19376.1.8.1.2.3 Macroscopic Observation Section (2014‑05‑13 11:57:09)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

where [@typeCode='COMP'] [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.2.3']]]

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

bl

1 … 1

F

true

hl7:component

0 … 1

R

   The Microscopic Observation section contains optionally the histopathologic findings of the case and many laboratories use this section to record the results of histochemical and immunohistochemical stains.

Contains 1.3.6.1.4.1.19376.1.8.1.2.4 Microscopic Observation Section (2014‑05‑13 14:25:17)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

where [@typeCode='COMP'] [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.2.4']]]

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

bl

1 … 1

F

true

hl7:component

0 … 1

R

The Additional Specific Observation section includes additional pathologic finding(s) and the results of ancillary study(ies) with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken.

Contains 1.3.6.1.4.1.19376.1.3.10.3.1 Additional Specified Observation Section (2016‑11‑13 14:28:08)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

where [@typeCode='COMP'] [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.3.1']]]

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

bl

1 … 1

F

true

hl7:component

1 … 1

M

   The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.

Contains 1.3.6.1.4.1.19376.1.8.1.2.5 Diagnostic Conclusion Section (2014‑05‑13 19:31:26)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

where [@typeCode='COMP'] [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.2.5']]]

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

bl

1 … 1

F

true

hl7:component

0 … 1

R

   The Procedure steps section contains the description of tissue dissection: representative specimens and derived specimens dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, electron microscopy, etc.) or biorepository.

Contains 1.3.6.1.4.1.19376.1.8.1.2.6 Procedure Steps Section (2014‑05‑13 19:33:12)

PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module

where [@typeCode='COMP'] [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.2.6']]]

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

bl

1 … 1

F

true

6.2.4 CDA R2 <section> Content Modules

6.2.4.1 Clinical Information <section> - 1.3.6.1.4.1.19376.1.8.1.2.1

6.2.4.1.1 Definition and Purpose

The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, reason for anatomic pathology procedure, clinical laboratory data, specimen collection procedure including target site, performer, specimen type, specimen(s) clinical description, and tumor site in case of a cancer.

6.2.4.1.2 Specification and Example

Id 1.3.6.1.4.1.19376.1.8.1.2.1 Effective Date valid from 2014‑05‑13 14:38:08

Status Draft Version Label 2.0

Name ClinicalInformationSection Display Name Clinical Information Section

Description

The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, reason for anatomic pathology procedure, clinical laboratory data, information about specimens collected in this case (including target site, performer, specimen type, specimen(s) clinical description, and tumor site in case of a cancer).

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.1

Label PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information 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 5 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
1.3.6.1.4.1.19376.1.8.1.3.6	Containment	Problem Organizer (2.0)	2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.8.1.4.2	Include	CDA author IHE	2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.5.3.1.3.1	Containment	IHE Reason for Referral Section (2014)	2016‑09‑26 07:58:18
1.3.6.1.4.1.19376.1.5.3.1.3.4	Containment	IHE History of Present Illness Section (2014)	2013‑01‑31
1.3.6.1.4.1.19376.1.5.3.1.3.6	Containment	IHE Active Problems Section (2014)	2015‑10‑05 16:02:07

Relationship Specialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)

Example

generated example

<section classCode="DOCSECT" moodCode="EVN"> <templateId root="1.3.6.1.4.1.19376.1.8.1.2.1"/> <code code="22636-5" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report relevant history"/> <title>CLINICAL INFORMATION SECTION</title> <text/> <languageCode/> <entry xsi:type="ANY" typeCode="COMP" contextConductionInd="true">  </entry>  <component>  </component> <component>  </component> <component>  </component></section>

Item DT Card Conf Description Label

hl7:section

0 … 1

R

PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section

@classCode

cs

0 … 1

F

DOCSECT

@moodCode

cs

0 … 1

F

EVN

Constraint

   This section SHALL contain a code element populated with these attributes:

@code="22636-5"

@codeSystem="'2.16.840.1.113883.6.1"

@displayName=" Pathology report relevant history”

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) to be described. These entries provide the machine-readable data corresponding to the narrative block.

This section MAY contain a number of elements component/section introducing sub-sections, each of these sub-sections providing a particular type of clinical information.

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: 6.3.4.1 Clinical information section

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.8.1.2.1

hl7:code

CE

1 … 1

M

PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section

@code

CONF

1 … 1

F

22636-5

@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 relevant history

hl7:title

ST

1 … 1

R

PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section

CONF

element content shall be "CLINICAL INFORMATION SECTION"

Example <title>CLINICAL INFORMATION</title>

hl7:text

SD.TEXT

1 … 1

M

PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section

Example <text> Tissue submitted: left breast biopsy and apical axillary tissue </text>

hl7:languageCode

CS

0 … 1

PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (2014‑03‑26)

hl7:entry

ANY

0 … *

R

Problem organizer
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: 6.3.4.1 Clinical information section

where [hl7:organizer [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.3.6']]]

@typeCode

cs

0 … 1

F

COMP

@contextConductionInd

bl

0 … 1

F

true

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)
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2

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:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

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

@determinerCode

0 … 1

F

INSTANCE

hl7:name

PN

0 … *

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

hl7:assignedAuthoringDevice

0 … 1

C

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:manufacturerModelName

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:representedOrganization

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

@determinerCode

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

@determinerCode

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:component

0 … 1

Subsection

Source: PCC TF-2: 6.3.3.1.1
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.1 IHE Reason for Referral Section (2016‑09‑26 07:58:18)

PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section

where [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.1']]]

hl7:component

0 … 1

Subsection

Source: PCC TF-2: 6.3.3.2.1
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 IHE History of Present Illness Section (2013‑01‑31)

PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section

where [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.4']]]

hl7:component

0 … 1

Subsection

Source: PCC TF-2: 6.3.3.2.3
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.6 IHE Active Problems Section (2015‑10‑05 16:02:07)

PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section

where [hl7:section [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.3.6'] and hl7:templateId [@root='2.16.840.1.113883.10.20.1.11']]]

6.2.4.2 Intraoperative Observation <section> - 1.3.6.1.4.1.19376.1.8.1.2.2

6.2.4.2.1 Definition and Purpose

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).

6.2.4.2.2 Specification and Example

LOINC code has been ordered. GH

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/>  <entry typeCode="COMP" contextConductionInd="true">  </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:languageCode

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:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

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

@determinerCode

0 … 1

F

INSTANCE

hl7:name

PN

0 … *

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

hl7:assignedAuthoringDevice

0 … 1

C

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:manufacturerModelName

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:representedOrganization

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

@determinerCode

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

@determinerCode

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

@contextConductionInd

bl

0 … 1

F

true

6.2.4.3 Macroscopic Observation <section> - 1.3.6.1.4.1.19376.1.8.1.2.3

6.2.4.3.1 Definition and Purpose

The Macroscopic Observation section contains the description of the specimen(s) received or obtained by the laboratory (specimen type and state), the gross observation, links to gross images, if taken, processing information and tissue disposition (representative sampling and tissue submitted for additional studies or sent to biorepository.

6.2.4.3.2 Specification and Example

The only entry is Problem Organizer instead of Specimen information organizer. GH

Id 1.3.6.1.4.1.19376.1.8.1.2.3 Effective Date valid from 2014‑05‑13 11:57:09

Status Draft Version Label 2.0

Name MacroscopySection Display Name Macroscopic Observation Section

Description

The Macroscopic Observation section contains the description of the specimen(s) received or obtained by the laboratory (specimen type and state), the gross observation, links to gross images, if taken, processing information and tissue disposition (representative sampling and tissue submitted for additional studies or sent to biorepository.

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.3

Label PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic 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

<section> <templateId root="1.3.6.1.4.1.19376.1.8.1.2.3"/> <code code="22634-0" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report gross observation"/> <title>MACROSCOPIC OBSERVATION SECTION</title> <text/>  <entry typeCode="COMP">  </entry></section>

Item DT Card Conf Description Label

hl7:section

0 … 1

R

PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section

Constraint

   This section SHALL contain a code element populated with these attributes:

@code ="22634-0"

@codeSystem ="2.16.840.1.113883.6.1"

@displayName ="Pathology report gross observation"

This section does not contain any subsection. The 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 to be described. These entries provide the machine-readable data corresponding to the narrative block.

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

M

PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.8.1.2.3

hl7:code

CE

1 … 1

M

PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section

@code

CONF

1 … 1

F

22634-0

@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 gross observation

hl7:title

ST

1 … 1

R

PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section

CONF

element content shall be "MACROSCOPIC OBSERVATION SECTION"

Example <title>Macroscopic Observation</title>

hl7:text

SD.TEXT

1 … 1

M

PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section

Example

example for use case #1

<text>A. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)</text>

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: 6.3.6.2

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:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

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

@determinerCode

0 … 1

F

INSTANCE

hl7:name

PN

0 … *

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

hl7:assignedAuthoringDevice

0 … 1

C

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:manufacturerModelName

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:representedOrganization

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

@determinerCode

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

@determinerCode

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: PaLM Suppl. APSR 2.0-3: 6.2.5.2
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: 6.3.4.3 Macroscopic 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

@contextConductionInd

bl

0 … 1

F

true

6.2.4.4 Microscopic Observation <section> - 1.3.6.1.4.1.19376.1.8.1.2.4

6.2.4.4.1 Definition and Purpose

The Microscopic Observation section contains optionally the histopathologic findings of the case and many laboratories use this section to record the results of histochemical and immunohistochemical stains.

6.2.4.4.2 Specification and Example

The only entry is Problem Organizer instead of Specimen information organizer. GH

Id 1.3.6.1.4.1.19376.1.8.1.2.4 Effective Date valid from 2014‑05‑13 14:25:17

Status Draft Version Label 2.0

Name MicroscopySection Display Name Microscopic Observation Section

Description

The Microscopic Observation section contains optionally the histopathologic findings of the case and of all of the derived specimens. This section should be used to record the results of histochemical and immunohistochemical stains and of image-based molecular methods.

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.4

Label PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic 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

<section> <templateId root="1.3.6.1.4.1.19376.1.8.1.2.4"/> <code code="22635-7" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report microscopic observation"/> <title>MICROSCOPIC OBSERVATION SECTION</title> <text/>  <entry>  </entry></section>

Item DT Card Conf Description Label

hl7:section

0 … 1

R

PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section

Constraint

   This section SHALL contain a code element populated with these attributes:

@code ="22635-7"

@codeSystem ="2.16.840.1.113883.6.1"

@displayName ="Pathology report microscopic observation"

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 to be described. These entries provide the machine-readable data corresponding to the narrative block.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

This section does not contain any subsections.

hl7:templateId

II

1 … 1

M

PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.8.1.2.4

hl7:code

CE

1 … 1

M

PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section

@code

CONF

1 … 1

F

22635-7

@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 microscopic observation

hl7:title

ST

1 … 1

R

PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section

CONF

element content shall be "MICROSCOPIC OBSERVATION SECTION"

Example <title>MICROSCOPIC OBSERVATION SECTION</title>

hl7:text

SD.TEXT

1 … 1

M

PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section

Example

example from use case#1

<text> INVASIVE ADENOCARCINOMA OF THE BREAST. <br/> HISTOLOGIC TYPE: DUCTAL. <br/> NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3. <list> <item>TUBULE FORMATION SCORE: 2.</item> <item>NUCLEAR PLEOMORPHISM SCORE: 2.</item> <item>MITOTIC RATE SCORE: 1.</item> </list> IN-SITU CARCINOMA: EQUIVOCAL. <br/> <br/> BREAST CANCER BIOMARKER STUDIES: <list> <item>PARAFFIN BLOCK NUMBER: A1.</item> <item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8, Allred Percentage Score = 5, Allred Staining Score = 3).</item> <item>PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED SCORE = 8).</item> <item>DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.</item> <item>HER2/NEU IMMUNOHISTOCHEMISTRY: EQUIVOCAL (2+) FOR OVEREXPRESSION OF HER2/NEU ONCOPROTEIN.</item> <item>HER2/NEU FISH RESULTS: NOT AMPLIFIED.</item> </list></text>

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: 6.3.6.2

hl7:author

0 … *

C

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

@typeCode

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1 … 1

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Example

author is a person

<author typeCode="AUT" contextControlCode="OP"> <time value="201306101654"/> <assignedAuthor classCode="ASSIGNED">  </assignedAuthor></author>

hl7:templateId

1 … 1

M

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@root

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1 … 1

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1.3.6.1.4.1.19376.1.8.1.4.2

hl7:time

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1 … 1

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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

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1 … *

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Choice

1 … 1

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Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

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

@determinerCode

0 … 1

F

INSTANCE

hl7:name

PN

0 … *

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0 … 1

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PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

@classCode

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0 … 1

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0 … 1

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0 … 1

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hl7:softwareName

SC

0 … 1

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PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

hl7:code

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0 … 1

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PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

hl7:representedOrganization

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

@determinerCode

0 … 1

F

INSTANCE

hl7:id

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0 … 1

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0 … 1

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

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hl7:addr

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hl7:standardIndustryClassCode

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PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

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@codeSystem

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2.16.840.1.113883.5.111 (Role Code)

hl7:statusCode

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0 … 1

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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

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0 … 1

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hl7:entry

0 … *

R

Problem organizer entry

Source: PaLM Suppl. APSR 2.0-3:

6.2.5.2
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: 6.3.4.4 Microscopic 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

@contextConductionInd

bl

0 … 1

F

true

6.2.4.5 Diagnostic Conclusion <section> - 1.3.6.1.4.1.19376.1.8.1.2.5

6.2.4.5.1 Definition and Purpose

The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.

6.2.4.5.2 Specification and Example

The only entry is Problem Organizer instead of Specimen information organizer. GH

Id 1.3.6.1.4.1.19376.1.8.1.2.5 Effective Date valid from 2014‑05‑13 19:31:26

Status Draft Version Label 2.0

Name DiagnosticConclusionSection Display Name Diagnostic Conclusion Section

Description

The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.5

Label PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion 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 3 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
1.3.6.1.4.1.19376.1.3.10.4.5	Containment	CDA Update Information Organizer (2.0)	2017‑11‑14 15:22:14
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="1.3.6.1.4.1.19376.1.8.1.2.5"/> <code code="22637-3" codeSystem="2.16.840.1.113883.6.1" displayName="'Pathology report diagnosis"/> <title>DIAGNOSTIC CONCLUSION SECTION</title> <text/>  <entry>  </entry> <entry>  </entry></section>

Item DT Card Conf Description Label

hl7:section

1 … 1

M

PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section

@classCode

cs

1 … 1

F

DOCSECT

@moodCode

cs

1 … 1

F

EVN

Constraint

         This section SHALL contain a code element populated with these attributes:

@code ="22637-3"

@codeSystem ="2.16.840.1.113883.6.1"

@displayName ="Pathology report diagnosis"

This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.

The section SHALL contain as many Problem Organizer entry elements as there are problems or groups thereof investigated. Each entry provides machine-readable data.

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

M

PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.8.1.2.5

hl7:code

CE

1 … 1

M

PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section

@code

CONF

1 … 1

F

22637-3

@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 diagnosis

hl7:title

ST

1 … 1

R

PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section

CONF

element content shall be "DIAGNOSTIC CONCLUSION SECTION"

hl7:text

SD.TEXT

1 … 1

M

PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section

Example

example for use case#1

<text> <paragraph> A1. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY) </paragraph> INVASIVE ADENOCARCINOMA OF THE BREAST. <br/> HISTOLOGIC TYPE: DUCTAL. <br/> NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3. <list> <item>TUBULE FORMATION SCORE: 2.</item> <item>NUCLEAR PLEOMORPHISM SCORE: 2.</item> <item>MITOTIC RATE SCORE: 1.</item> </list> ICD-O-CLASSIFICATION: C50.3 M8500/31 <br/> IN-SITU CARCINOMA: EQUIVOCAL. <br/> <br/> BREAST CANCER BIOMARKER STUDIES: <list> <item>PARAFFIN BLOCK NUMBER: A1.</item> <item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8, Percentage stained tumor cells = 85%, Allred Staining Score = 3).</item> <item>PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED SCORE = 8).</item> <item>DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.</item> <item>HER2/NEU IMMUNOHISTOCHEMISTRY: EQUIVOCAL (2+) FOR OVEREXPRESSION OF HER2/NEU ONCOPROTEIN.</item> <item>HER2/NEU FISH RESULTS: NOT AMPLIFIED.</item> </list></text>

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: 
         6.3.6.2

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

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0 … 1

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ASSIGNED

hl7:id

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1 … *

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PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

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1 … *

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PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

hl7:telecom

TEL

1 … *

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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:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

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

@determinerCode

0 … 1

F

INSTANCE

hl7:name

PN

0 … *

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

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PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

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0 … 1

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PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

hl7:softwareName

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0 … 1

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PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

hl7:code

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0 … 1

R

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

hl7:representedOrganization

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

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@determinerCode

0 … 1

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hl7:id

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0 … 1

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0 … 1

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0 … 1

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hl7:addr

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0 … 1

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0 … 1

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PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

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0 … 1

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

@classCode

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hl7:code

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0 … 1

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@codeSystem

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0 … 1

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2.16.840.1.113883.5.111 (Role Code)

hl7:statusCode

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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

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PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

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0 … *

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

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0 … 1

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PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

hl7:entry

0 … 1

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Source: PaLM Suppl. APSR 2.0-3: 6.2.5.4

Contains 1.3.6.1.4.1.19376.1.3.10.4.5 CDA Update Information Organizer (2017‑11‑14 15:22:14)

PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section

where [@typeCode='COMP'] [hl7:organizer [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.4.5']]]

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

bl

0 … 1

F

true

Constraint if ClinicalDocument.versionNumber > 1

hl7:entry

1 … *

M

Source: PaLM Suppl. APSR 2.0-3: 6.2.5.2

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: 6.3.4.6 Diagnostic conclusion 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

@contextConductionInd

bl

0 … 1

F

true

6.2.4.6 Procedure steps <section> - 1.3.6.1.4.1.19376.1.8.1.2.6

6.2.4.6.1 Definition and Purpose

The Procedure steps section contains the description of tissue dissection: representative specimens and derived specimens dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, electron microscopy, etc.) or biorepository. The only entry for this section is the Specimen Procedure Steps Entry module.

6.2.4.6.2 Specification and Example

Id 1.3.6.1.4.1.19376.1.8.1.2.6 Effective Date valid from 2014‑05‑13 19:33:12

Status Draft Version Label 2.0

Name ProcedureStepsSection Display Name Procedure Steps Section

Description

The Procedure steps section contains the description of tissue dissection: representative specimens and derived specimens dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, electron microscopy, etc.) or biorepository.

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.6

Label PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps 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
1.3.6.1.4.1.19376.1.3.10.4.1	Containment	Specimen Procedure Step (2.0)	2016‑07‑08 13:20:59

Relationship Specialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)

Example

<section classCode="DOCSECT" moodCode="EVN"> <templateId root="1.3.6.1.4.1.19376.1.8.1.2.6"/> <code code="46059-2" codeSystem="2.16.840.1.113883.6.1" displayName="Special treatments and procedures section"/> <title>PROCEDURE STEPS SECTION</title> <text/>  <entry typeCode="COMP" contextConductionInd="false">  </entry></section>

Item DT Card Conf Description Label

hl7:section

0 … 1

R

PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section

@classCode

cs

0 … 1

F

DOCSECT

@moodCode

cs

0 … 1

F

EVN

Constraint

   This section SHALL contain a code element populated with these attributes:

@code ="46059-2"

@codeSystem ="2.16.840.1.113883.6.1"

@displayName ="Special treatments and procedures section"

This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

The section SHOULD contain as many Specimen Procedure Steps entry elements as there are procedure steps or groups thereof to be described. These entries provide the machine-readable data corresponding to the narrative block.

hl7:templateId

II

1 … 1

M

PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.8.1.2.6

hl7:code

CE

1 … 1

M

PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section

@code

CONF

1 … 1

F

46059-2

@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

Special treatments and procedures section

hl7:title

ST

1 … 1

R

PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section

CONF

element content shall be "PROCEDURE STEPS SECTION"

hl7:text

SD.TEXT

1 … 1

M

PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section

Example

example for use case#1

<text> RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY) <br/> PARAFFIN BLOCK NUMBER: A1.:FOUR SECTIONS FOR EACH STAIN: <br/> <paragraph ID="A7102400008">RIGHT BREAST FIVE CORES 8-9:00</paragraph> <paragraph ID="block_A_1">PARAFFIN BLOCK NUMBER: A1</paragraph> <paragraph ID="slide_A_1_HE">slide from block A1 HE stained</paragraph> <paragraph ID="slide_A_1_ER">slide from block A1 ER Immunohistochemistry</paragraph> <paragraph ID="slide_A_1_PR">slide from block A1 PR Immunohistochemistry</paragraph> <paragraph ID="slide_A_1_EGFR">slide from block A1 EGFR (PharmDX) Immunohistochemistry</paragraph> <paragraph ID="slide_A_1_HER2">slide from block A1 HER2 Immunohistochemistry</paragraph> <paragraph ID="slide_A_1_HER2_FISH">slide block from A1 HER2 FISH</paragraph></text>

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 2.0‑3:6.3.6.2

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:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

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

@determinerCode

0 … 1

F

INSTANCE

hl7:name

PN

0 … *

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

hl7:assignedAuthoringDevice

0 … 1

C

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:manufacturerModelName

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:representedOrganization

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

@determinerCode

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

@determinerCode

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

Specimen procedure steps

Source: PaLM Suppl.APSR 2.0‑3:6.2.5.3
Contains 1.3.6.1.4.1.19376.1.3.10.4.1 Specimen Procedure Step (2016‑07‑08 13:20:59)

PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section

where [@typeCode='COMP'] [hl7:procedure [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.4.1']]]

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

bl

0 … 1

6.2.4.7 Report Textual Summary <section> - 1.3.6.1.4.1.19376.1.8.1.2.7

6.2.4.7.1 Definition and Purpose

The Report Textual Summary section is an optional sub-section of the Diagnostic Conclusion section. This section contains a textual summary of the AP report, which can be extracted from the document and inserted into other clinical documents. It addresses the use case where authors of other medical documents feel the need to include a segment such as "...the pathology report states '[...]'", the text content of this section filling the brackets.

6.2.4.7.2 Specification and Example

Keine Versionen mit Status draft, active, review oder pending.

Should a Laboratory specialty section (1.3.6.1.4.1.19376.1.3.3.2.1) for Molecular pathology be included? GH

6.2.5 CDA R2 <entry> Content Modules

6.2.5.1 Common Specification for all APSR Entry Content Modules

The unique <entry> Content Module available in all the sections except Procedure Steps <section> of the APSR template is Problem Organizer.

The unique <entry> Content Module available in Procedure Steps <section> of the APSR template is Specimen Procedure Step

Each <entry> Content Module carries machine-readable data related to one Problem on one specimen or on a group of specimens observed for this section.

Each <entry> Content Module is repeatable below its section, so as to support the use cases where a section reports on more than one specimen or more than one group of specimens.

6.2.6 CDA R2 Child Element Content Modules

This section specifies the Content Modules designed for child elements. A child element is a child of the CDA header or a child of a <section>, or an element nested at various depths below an <entry>, or an element appearing at some combination of these locations.

6.2.6.1 Specimen Collector in Header – 1.3.6.1.4.1.19376.1.8.1.4.1

6.2.6.1.1 Definition and purpose

This Content Module is usable only in the CDA header.

This Content Module is used only in the situation where the specimen was not collected by the ordering physician. (See use cases in volume 1)

6.2.6.1.2 Specification and Example

Id 1.3.6.1.4.1.19376.1.8.1.4.1 Effective Date valid from 2016‑06‑13 14:21:13

Status Draft Version Label

Name CDAParticipantSpecimenCollector Display Name CDA Participant Specimen Collector

Description

Template CDA participant (prototype, directly derived from POCD_RM000040 MIF)

This Content Module is usable only in the CDA header.

This Content Module is used only in the situation where the specimen was not collected by the ordering physician.

Label PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

Classification CDA Header 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	Include	Anatomic Pathology Structured Report Content Module (2.0)	2014‑05‑13 11:57:57
Uses	as	Name	Version
2.16.840.1.113883.10.12.152	Containment	CDA Person	2005‑09‑07
2.16.840.1.113883.10.12.151	Containment	CDA Organization	2005‑09‑07

Relationship Specialization: template 2.16.840.1.113883.10.12.108 (2005‑09‑07)

Example

generated example

Item DT Card Conf Description Label

hl7:participant

0 … *

R

The Specimen Collector Content Module is only used in case a specimen provided as input to the AP act documented in this report, was collected by a different party than the ordering physician. In that case, this specimen collector is represented in the CDA header as a participant element with the typeCode attribute valued “DIST” and the sub-element participant/time carries the time period of the specimen collection.

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

@typeCode

cs

1 … 1

F

DIST

hl7:templateID

II

1 … 1

M

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.8.1.4.1

hl7:time

IVL_TS

1 … 1

M

Specimen collection time

The specimen collection time is an interval, which may be reduced to a point in time (see usage of data type IVL_TS).

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

hl7:associatedEntity

0 … 1

R

At least one of the two elements

associatedPerson and scopingOrganization must be present. Both may be present.

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

@classCode

cs

1 … 1

F

PROV

hl7:id

II

1 … *

R

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

hl7:addr

AD

1 … *

R

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

hl7:telecom

TEL.AT

1 … *

R

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

hl7:associatedPerson

0 … *

C

Person who collected the specimen.
Only full name(s) SHALL be given.
Contains 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

hl7:scopingOrganization

0 … 1

C

Organization taking care for specimen collection.
Identifiers, name, telecom, and address SHOULD be given.
Contains 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)

PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

6.2.6.2 Author – 1.3.6.1.4.1.19376.1.8.1.4.2

6.2.6.2.1 Definition and purpose

This Content Module is usable in the CDA header, in a <section> and at various depths of an <entry>.

It describes an author having contributed to the document wholly or to a portion of it (e.g., a section, an observation, a group of observations).

A given document or any delimited portion of it may have more than one author.

An author MAY be a person or a device (manufactured device or software system). In both cases the scoping organization MAY be described.

6.2.6.2.2 Specification and Example

Id 1.3.6.1.4.1.19376.1.8.1.4.2 Effective Date valid from 2016‑06‑21 14:02:11

Status Draft Version Label

Name CDAAuthorIHE Display Name CDA author IHE

Description

Template CDA author (prototype, directly derived from POCD_RM000040 MIF).

   
   
This Content Module is usable in the CDA header, in a <section> and at various depths of an <entry>.

It describes an author having contributed to the document wholly or to a portion of it (e.g., a section, an observation, a group of observations).

   
A given document or any delimited portion of it may have more than one author.

An author MAY be a person or a device (manufactured device or software system). In both cases the scoping organization MAY be described.

Label PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

Classification CDA Header Level Template

Open/Closed Open (other than defined elements are allowed)

Used by / Uses

Used by 0 transactions and 34 templates, Uses 2 templates

Used by	as	Name	Version
1.3.6.1.4.1.19376.1.3.10.3.1	Include	Additional Specified Observation Section (2.0)	2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.1.1		Anatomic Pathology Structured Report Content Module (2.0)	2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.1	Include	Clinical Information Section (2.0)	2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2	Include	Intraoperative Observation Section (2.0)	2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3	Include	Macroscopic Observation Section (2.0)	2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4	Include	Microscopic Observation Section (2.0)	2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5	Include	Diagnostic Conclusion Section (2.0)	2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.2.6	Include	Procedure Steps Section (2.0)	2014‑05‑13 19:33:12
1.3.6.1.4.1.19376.1.8.1.2.7	Include	Report Textual Summary Section (2.0)	2016‑06‑13 17:54:42
1.3.6.1.4.1.19376.1.3.10.4.1	Containment	Specimen Procedure Step (2.0)	2016‑07‑08 13:20:59
	Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.3.10.4.1		Specimen Procedure Step (1.0)	2014‑07‑29 16:02:02
	Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.3.10.4.2	Containment	TNM Stage Observation (2.0)	2014‑05‑13 15:45:13
1.3.6.1.4.1.19376.1.3.10.4.3	Containment	ICD-O-3 Typing and Grading Observation (2.0)	2015‑11‑29 17:03:18
1.3.6.1.4.1.19376.1.3.10.4.4	Containment	Assessment Scales Observation for Scoring Systems APSR2 (2.0)	2016‑10‑06 13:12:00
1.3.6.1.4.1.19376.1.3.10.4.5	Containment	CDA Update Information Organizer (2.0)	2017‑11‑14 15:22:14
1.3.6.1.4.1.19376.1.3.10.9.22	Containment	CDA Supply Container APSR2 (2.0)	2016‑07‑29 12:09:33
1.3.6.1.4.1.19376.1.3.10.9.25	Containment	TNM T-Observation (2.0)	2014‑12‑02 15:54:17
1.3.6.1.4.1.19376.1.3.10.9.26	Containment	TNM N-Observation (2.0)	2014‑12‑02 16:34:50
1.3.6.1.4.1.19376.1.3.10.9.27	Containment	TNM M-Observation (2.0)	2014‑12‑02 16:32:30
1.3.6.1.4.1.19376.1.3.10.9.28	Containment	TNM Grading (2.0)	2015‑11‑15 13:01:18
1.3.6.1.4.1.19376.1.3.10.9.29	Containment	TNM R-status (2.0)	2015‑06‑30 13:38:30
1.3.6.1.4.1.19376.1.3.10.9.30	Containment	TNM a (2.0)	2015‑06‑22 15:13:46
1.3.6.1.4.1.19376.1.3.10.9.31	Containment	TNM r (2.0)	2015‑06‑22 17:38:42
1.3.6.1.4.1.19376.1.3.10.9.32	Containment	TNM y (2.0)	2015‑06‑22 17:28:17
1.3.6.1.4.1.19376.1.3.10.9.33	Containment	TNM Serum tumor markers (2.0)	2015‑11‑06 14:28:44
1.3.6.1.4.1.19376.1.3.10.9.34	Containment	TNM Lymphatic Invasion (2.0)	2015‑11‑16 14:01:58
1.3.6.1.4.1.19376.1.3.10.9.35	Containment	TNM Venous Invasion (2.0)	2015‑11‑16 13:40:28
1.3.6.1.4.1.19376.1.3.10.9.36	Containment	TNM Perineural Invasion (2.0)	2015‑11‑11 16:13:40
1.3.6.1.4.1.19376.1.3.10.9.37	Containment	TNM Number of nodes (2.0)	2014‑12‑02 16:48:36
1.3.6.1.4.1.19376.1.3.10.9.43	Containment	Assessment Scoring Item APSR 2.0 (2.0)	2016‑10‑11 10:26:17
1.3.6.1.4.1.19376.1.3.10.9.42		Assessment Scoring System APSR 2.0 (2.0)	2016‑10‑10 11:33:36
1.3.6.1.4.1.19376.1.8.1.3.6	Containment	Problem Organizer (2.0)	2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.8.1.4.10	Containment	Embedded Image IHE	2016‑06‑22 16:08:01
1.3.6.1.4.1.19376.1.8.1.4.9		AP Observation Entry (2.0)	2014‑05‑14 17:09:54
	Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
Uses	as	Name	Version
2.16.840.1.113883.10.12.152	Include	CDA Person	2005‑09‑07
2.16.840.1.113883.10.12.151	Include	CDA Organization	2005‑09‑07

Relationship Adaptation: template 2.16.840.1.113883.10.12.102 (DYNAMIC)

Example

author is a person

<author typeCode="AUT"> <functionCode code="DISPHYS" displayName="discharging physician" codeSystem="2.16.840.1.113883.5.88" codeSystemName="ParticipationFunction"/> <time value="20130407130000+0500"/> <assignedAuthor classCode="ASSIGNED"> <assignedPerson classCode="PSN" determinerCode="INSTANCE"> <name> <given>Marie</given> <family>Müller</family> </name> </assignedPerson> <representedOrganization> <id root="2.16.840.1.113883.19.5"/> <name>Beispiel Krankenhaus</name> </representedOrganization> </assignedAuthor></author>

Example

author is a device

<author typeCode="AUT"> <assignedAuthor classCode="ASSIGNED"> <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <code>...</code> </assignedAuthoringDevice> </assignedAuthor></author>

Item DT Card Conf Description Label

hl7:author

0 … *

R

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:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

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

@determinerCode

0 … 1

F

INSTANCE

hl7:name

PN

0 … *

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

hl7:assignedAuthoringDevice

0 … 1

C

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:manufacturerModelName

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:representedOrganization

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

@determinerCode

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

@determinerCode

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

6.2.6.3 Content Validator – 1.3.6.1.4.1.19376.1.8.1.4.3

6.2.6.3.1 Definition and purpose

This Content Module is usable only in the CDA header.

It describes a pathologist having verified the content of the report, using the element authenticator. This element authenticator is used when the pathologist having verified the content of the report is distinct from the pathologist assuming the legal responsibility for this report, described in the legalAuthenticator element.

The report MAY have zero or more Content Validators.

6.2.6.3.2 Specification and Example

Id 1.3.6.1.4.1.19376.1.8.1.4.2 Effective Date valid from 2016‑06‑21 14:02:11

Status Draft Version Label

Name CDAAuthorIHE Display Name CDA author IHE

Description

Template CDA author (prototype, directly derived from POCD_RM000040 MIF).

   
   
This Content Module is usable in the CDA header, in a <section> and at various depths of an <entry>.

It describes an author having contributed to the document wholly or to a portion of it (e.g., a section, an observation, a group of observations).

   
A given document or any delimited portion of it may have more than one author.

An author MAY be a person or a device (manufactured device or software system). In both cases the scoping organization MAY be described.

Label PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

Classification CDA Header Level Template

Open/Closed Open (other than defined elements are allowed)

Used by / Uses

Used by 0 transactions and 34 templates, Uses 2 templates

Used by	as	Name	Version
1.3.6.1.4.1.19376.1.3.10.3.1	Include	Additional Specified Observation Section (2.0)	2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.1.1		Anatomic Pathology Structured Report Content Module (2.0)	2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.1	Include	Clinical Information Section (2.0)	2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2	Include	Intraoperative Observation Section (2.0)	2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3	Include	Macroscopic Observation Section (2.0)	2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4	Include	Microscopic Observation Section (2.0)	2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5	Include	Diagnostic Conclusion Section (2.0)	2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.2.6	Include	Procedure Steps Section (2.0)	2014‑05‑13 19:33:12
1.3.6.1.4.1.19376.1.8.1.2.7	Include	Report Textual Summary Section (2.0)	2016‑06‑13 17:54:42
1.3.6.1.4.1.19376.1.3.10.4.1	Containment	Specimen Procedure Step (2.0)	2016‑07‑08 13:20:59
	Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.3.10.4.1		Specimen Procedure Step (1.0)	2014‑07‑29 16:02:02
	Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.3.10.4.2	Containment	TNM Stage Observation (2.0)	2014‑05‑13 15:45:13
1.3.6.1.4.1.19376.1.3.10.4.3	Containment	ICD-O-3 Typing and Grading Observation (2.0)	2015‑11‑29 17:03:18
1.3.6.1.4.1.19376.1.3.10.4.4	Containment	Assessment Scales Observation for Scoring Systems APSR2 (2.0)	2016‑10‑06 13:12:00
1.3.6.1.4.1.19376.1.3.10.4.5	Containment	CDA Update Information Organizer (2.0)	2017‑11‑14 15:22:14
1.3.6.1.4.1.19376.1.3.10.9.22	Containment	CDA Supply Container APSR2 (2.0)	2016‑07‑29 12:09:33
1.3.6.1.4.1.19376.1.3.10.9.25	Containment	TNM T-Observation (2.0)	2014‑12‑02 15:54:17
1.3.6.1.4.1.19376.1.3.10.9.26	Containment	TNM N-Observation (2.0)	2014‑12‑02 16:34:50
1.3.6.1.4.1.19376.1.3.10.9.27	Containment	TNM M-Observation (2.0)	2014‑12‑02 16:32:30
1.3.6.1.4.1.19376.1.3.10.9.28	Containment	TNM Grading (2.0)	2015‑11‑15 13:01:18
1.3.6.1.4.1.19376.1.3.10.9.29	Containment	TNM R-status (2.0)	2015‑06‑30 13:38:30
1.3.6.1.4.1.19376.1.3.10.9.30	Containment	TNM a (2.0)	2015‑06‑22 15:13:46
1.3.6.1.4.1.19376.1.3.10.9.31	Containment	TNM r (2.0)	2015‑06‑22 17:38:42
1.3.6.1.4.1.19376.1.3.10.9.32	Containment	TNM y (2.0)	2015‑06‑22 17:28:17
1.3.6.1.4.1.19376.1.3.10.9.33	Containment	TNM Serum tumor markers (2.0)	2015‑11‑06 14:28:44
1.3.6.1.4.1.19376.1.3.10.9.34	Containment	TNM Lymphatic Invasion (2.0)	2015‑11‑16 14:01:58
1.3.6.1.4.1.19376.1.3.10.9.35	Containment	TNM Venous Invasion (2.0)	2015‑11‑16 13:40:28
1.3.6.1.4.1.19376.1.3.10.9.36	Containment	TNM Perineural Invasion (2.0)	2015‑11‑11 16:13:40
1.3.6.1.4.1.19376.1.3.10.9.37	Containment	TNM Number of nodes (2.0)	2014‑12‑02 16:48:36
1.3.6.1.4.1.19376.1.3.10.9.43	Containment	Assessment Scoring Item APSR 2.0 (2.0)	2016‑10‑11 10:26:17
1.3.6.1.4.1.19376.1.3.10.9.42		Assessment Scoring System APSR 2.0 (2.0)	2016‑10‑10 11:33:36
1.3.6.1.4.1.19376.1.8.1.3.6	Containment	Problem Organizer (2.0)	2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.8.1.4.10	Containment	Embedded Image IHE	2016‑06‑22 16:08:01
1.3.6.1.4.1.19376.1.8.1.4.9		AP Observation Entry (2.0)	2014‑05‑14 17:09:54
	Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
Uses	as	Name	Version
2.16.840.1.113883.10.12.152	Include	CDA Person	2005‑09‑07
2.16.840.1.113883.10.12.151	Include	CDA Organization	2005‑09‑07

Relationship Adaptation: template 2.16.840.1.113883.10.12.102 (DYNAMIC)

Example

author is a person

<author typeCode="AUT"> <functionCode code="DISPHYS" displayName="discharging physician" codeSystem="2.16.840.1.113883.5.88" codeSystemName="ParticipationFunction"/> <time value="20130407130000+0500"/> <assignedAuthor classCode="ASSIGNED"> <assignedPerson classCode="PSN" determinerCode="INSTANCE"> <name> <given>Marie</given> <family>Müller</family> </name> </assignedPerson> <representedOrganization> <id root="2.16.840.1.113883.19.5"/> <name>Beispiel Krankenhaus</name> </representedOrganization> </assignedAuthor></author>

Example

author is a device

<author typeCode="AUT"> <assignedAuthor classCode="ASSIGNED"> <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <code>...</code> </assignedAuthoringDevice> </assignedAuthor></author>

Item DT Card Conf Description Label

hl7:author

0 … *

R

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:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

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

@determinerCode

0 … 1

F

INSTANCE

hl7:name

PN

0 … *

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

hl7:assignedAuthoringDevice

0 … 1

C

PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

@classCode

cs

0 … 1

F

DEV

@determinerCode

cs

0 … 1

F

INSTANCE

hl7:manufacturerModelName

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:representedOrganization

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

@determinerCode

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

@determinerCode

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

6.2.6.4 Specimen Procedure Step - 1.3.6.1.4.1.19376.1.3.10.4.1

This is an addendum to the reference text of APSR 2.0 GH

6.2.6.4.1 Definition and purpose

The Specimen Procedure Step <entry> Content Modul contains in machine-readable form all the information concerning one specimen or a group of specimens. It is usable within a Procedure Steps <section> Content Module only.

This Content Module structures the machine-readable data, which characterize the specimens and the procedures of their collection and processing (identifiers and types, time intervals, performers, approach site, target site). By referencing the child procedure ID via an entryRelationship the entry is used in an iterative manner for each single step of specimen collection and processing, which results in derived (child) specimen in and on the appropriate containers. The resulting specimen is the participant in the procedure according the CDA-RIM (fig. 6.2.6.11.1-1). Specimen and their container carry IDs as well as further attributes, which are defined in the HL7 Specimen DAM.

HL7 DAM Specimen Release 1.

According to the CDA RIM in the Content Module further supporting Content Modules for Participant and Playing Entity are needed, which have the (preliminary) OIDs 1.3.6.1.4.1.19376.1.3.10.9.20 and 1.3.6.1.4.1.19376.1.3.10.9.21)

Figure 6.2.6.4.1-1 CDA-RMIM of the Specimen Procedure Steps <entry>

The Code systems and Value sets MAY be organized organ-specific and represented e.g. by PathLex.

@Riki:Should the containers be included in the model? I tried this by a CDA Supply construct in the Playing entity. Correct? GH

@Riki:Should parent IDs be included in the model? By a CDA Reference construct, as proposed for the procedure ID by Frank? GH

6.2.6.4.2 Specification and Example

Id

1.3.6.1.4.1.19376.1.3.10.4.1

Effective Date

valid from 2016‑07‑08 13:20:59

There are versions of templates with this id:

SpecimenProcedureStep as of 2016‑07‑08 13:20:59
SpecimenProcedureStep as of 2014‑07‑29 16:02:02

Status Draft Version Label 2.0

Name SpecimenProcedureStep Display Name Specimen Procedure Step

Description

Template CDA Procedure (prototype, directly derived from 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.

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.1

Label PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

Classification CDA Entry Level Template

Open/Closed Open (other than defined elements are allowed)

Used by / Uses

Used by 0 transactions and 4 templates, Uses 8 templates

Used by	as	Name	Version
1.3.6.1.4.1.19376.1.3.10.4.1	Containment	Specimen Procedure Step (2.0)	2016‑07‑08 13:20:59
	Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.3.10.4.1		Specimen Procedure Step (1.0)	2014‑07‑29 16:02:02
	Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.8.1.2.6		Procedure Steps Section (2.0)	2014‑05‑13 19:33:12
1.3.6.1.4.1.19376.1.8.1.1.1		Anatomic Pathology Structured Report Content Module (2.0)	2014‑05‑13 11:57:57
Uses	as	Name	Version
1.3.6.1.4.1.19376.1.3.10.9.1	Include	X Specimen Identified	2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.3.3.1.7	Containment	Laboratory Performer (2017)	2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2	Containment	CDA author IHE	2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.3.10.9.44	Containment	CDA Participant (Body) Procedure Steps APSR2 (2.0)	2014‑10‑26 17:06:28
1.3.6.1.4.1.19376.1.3.10.9.22	Containment	CDA Supply Container APSR2 (2.0)	2016‑07‑29 12:09:33
1.3.6.1.4.1.19376.1.3.1.3	Containment	Specimen Received (2017)	2008‑08‑08
1.3.6.1.4.1.19376.1.3.10.4.1	Containment	Specimen Procedure Step (2.0)	2016‑07‑08 13:20:59
2.16.840.1.113883.10.12.324	Containment	CDA Reference	2005‑09‑07

Relationship Adaptation: template 2.16.840.1.113883.10.12.306 (2005‑09‑07)

Example

generated example

Item DT Card Conf Description Label

hl7:procedure

0 … *

R

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

@classCode

cs

1 … 1

F

PROC

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

R

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.3.10.4.1

hl7:id

II

0 … *

R

Procedure ID, coming from the LIS.
May be the target (referenced) ID for the child procedure.

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

hl7:code

CD (extensible)

1 … 1

M

Coded procedure

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

Constraint for specimen collection procedure codes for targetSite 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

The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.10 Specimen Collection and Processing (2016‑05‑31 15:09:59)

Example

for use case #1, specimen collection

<code code="122548005" codeSystem="2.16.840.1.113883.6.96" displayName="Biopsy of breast (procedure)" codeSystemName="SNOMED-CT"/>

Example

for use case #1, grossing & embedding

<code code="40923002" codeSystem="2.16.840.1.113883.6.96" displayName="Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)"/>

Example

for use case #1, sectioning & immunostaining

<code code="117617002" codeSystem="2.16.840.1.113883.6.96" displayName="Immunohistochemistry procedure (procedure)"/>

hl7:qualifier

CR (extensible)

0 … *

C

Qualifier for staining or other procedures which don´t have values in the vocabulary used.

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

Constraint Used only in staining and other procedures without values in SCT or LOINC or DICOM vocabulary, e.g. immune stains

Example

for use case #1, grossing & embedding

<qualifier> <name code="246355002" displayName="Supporting structure (attribute)" codeSystem="2.16.840.1.113883.6.96"/> <value code="702941008" displayName="Paraffin embedding (qualifier value)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/></qualifier>

Example

for use case #1, Estrogen receptor staining

<qualifier> <name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/> <value code="23307004" displayName="Estrogen receptor (substance)" codeSystem="2.16.840.1.113883.6.96"/></qualifier>

Example

for use case #1, ISH Her-2-neu staining

<qualifier> <name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/> <value code="164870" displayName="ONCOGENE ERBB2" codeSystem="2.16.840.1.113883.6.174" codeSystemName="OMIM"/></qualifier>

hl7:name

CV (extensible)

1 … 1

R

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

@code

cs

0 … 1

F

246094008_or_246355002

@codeSystem

oid

0 … 1

F

2.16.840.1.113883.6.96

@displayName

st

0 … 1

F

Component investigated (attribute) or Supporting structure (attribute)

hl7:value

CD (extensible)

1 … 1

R

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

@nullFlavor

cs

1 … 1

R

CONF

@code shall be "<<105590001 | Substance (substance) |"

@codeSystem shall be "2.16.840.1.113883.6.96"

@codeSystemName shall be "SNOMED-CT"

@displayName shall be "values from substance axis, e.g. Estrogen receptor"

or

@code shall be "values from G axis"

@codeSystem shall be "2.16.840.1.113883.6.174"

@codeSystemName shall be "OMIM"

@displayName shall be "values from G axis, e.g. erb-b2"

or

@code shall be "<<272394005 | Technique (qualifier value) |"

@codeSystem shall be "2.16.840.1.113883.6.96"

@codeSystemName shall be "SNOMED-CT"

@displayName shall be "values from technique axis, e.g. Paraffin embedded (qualifier)"

hl7:text

ED

0 … 1

R

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

Example

specimen collection procedure

<text>ULTRASOUND GUIDED NEEDLE CORE BIOPSY</text>

Example

specimen processing procedure

<text>CUTTING A SLIDE FROM A PARAFFIN BLOCK</text>

hl7:statusCode

CS (required)

0 … 1

R

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)

hl7:effectiveTime

IVL_TS

0 … 1

R

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

hl7:approachSiteCode

CD (extensible)

0 … 1

R

Approach site in specimen collection

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

@code

CONF

0 … 1

F

any_code

@codeSystem

0 … 1

F

2.16.840.1.113883.5.1052 (Act Site)

@codeSystemName

0 … 1

F

any_code

@displayName

0 … 1

F

ActSite

hl7:targetSiteCode

CD (extensible)

0 … 1

R

Target site in body or relative parent relationship in case of specimen processing

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

CONF

@code shall be "<<123037004 | Body structure (body structure) |"

@codeSystem shall be "2.16.840.1.113883.6.96"

@codeSystemName shall be "SCT"

@displayName shall be "all children of Body structure (body structure)"

or

@code shall be "any_code"

@codeSystem shall be "2.16.840.1.113883.5.1052"

@codeSystemName shall be "ActSite"

@displayName shall be "any_code"

or

The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.9 Procedure Site (2016‑06‑01 18:46:15)

Example

for use case #1, specimen collection

<targetSiteCode code="110497008" displayName="Lower outer quadrant of right breast (body structure)" codeSystem="2.16.840.1.113883.6.96"/>

Example

for use case #1, grossing & embedding

<targetSiteCode code="309050000" displayName="Body substance sample" codeSystem="2.16.840.1.113883.6.96"/>

hl7:qualifier

CR (extensible)

0 … *

C

optional qualifiers for specifying body structures or / and laterality

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

Example

for use case #1, (optional) specification of body structure for specimen collection

<qualifier> <name code="118169006" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen source topography (attribute)" codeSystemName="SNOMED-CT"/> <value code="255495000" codeSystem="2.16.840.1.113883.6.96" displayName="Right lower quadrant (qualifier value)" codeSystemName="SNOMED-CT"/></qualifier>

hl7:name

CV (extensible)

1 … 1

R

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

@displayName

st

0 … 1

F

Specimen source topography

@codeSystem

oid

1 … 1

F

2.16.840.1.113883.6.96

@code

cs

1 … 1

F

118169006

hl7:value

CD (extensible)

0 … *

R

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

@code

CONF

0 … 1

@code shall be out of choice:

<<272099008
Descriptor (qualifier value)

@codeSystem

0 … 1

F

2.16.840.1.113883.6.96 (SNOMED Clinical Terms)

@codeSystemName

0 … 1

F

SCT

@displayName

0 … 1

F

all children of "Descriptor, qualifier values", e.g. right lower quadrantt

hl7:methodCode

CD (extensible)

0 … *

R

Identifies the technique used to perform a procedure

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

@codeSystem

cs

1 … 1

F

2.16.840.1.113883.5.1065

Included 0 … 1 R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Parent specimen with parent ID

Example

for use case #1, parent specimen ID in grossing & embedding

<specimen typeCode="SPC"> <specimenRole classCode="SPEC">  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008"/> </specimenRole></specimen>

hl7:specimen

0 … 1

R

Required 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

@typeCode

cs

0 … 1

F

SPC

hl7:specimenRole

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified

@classCode

cs

0 … 1

F

SPEC

hl7:id

II

1 … 1

R

Specimen ID, coming from the LIS

PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified

hl7:performer

0 … 1

R

Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.3.1.7']]

hl7:author

0 … *

C

Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

where [hl7:author [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.2']]]

hl7:participant

1 … *

M

One or more specimen (with additives), which participates as product of the procedure
Contains 1.3.6.1.4.1.19376.1.3.10.9.44 CDA Participant (Body) Procedure Steps APSR2 (2014‑10‑26 17:06:28)

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

where [not(@nullFlavor)]

hl7:entryRelationship

0 … *

R

Artificial material (manufactured product) which
containes
the specimen
Contains 1.3.6.1.4.1.19376.1.3.10.9.22 CDA Supply Container APSR2 (2016‑07‑29 12:09:33)

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

where [@typeCode='COMP'] [hl7:supply [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.9.22']]]

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

bl

0 … 1

F

true

Constraint

for manufactured product

classCode = MANU

for DrugOrOtherMaterial
classCode = MMAT
code from MaterialEntityClassType

hl7:entryRelationship

0 … 1

R

Specimen arrival in Lab
Contains 1.3.6.1.4.1.19376.1.3.1.3 Specimen Received (2008‑08‑08)

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

where [@typeCode='COMP'] [hl7:act [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.1.3']]]

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

bl

0 … 1

F

true

hl7:entryRelationship

0 … *

R

Referencing mechanism to the ID of the child procedures, giving a lis of child procedure IDs
Contains 1.3.6.1.4.1.19376.1.3.10.4.1 Specimen Procedure Step (2016‑07‑08 13:20:59)

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

where [@typeCode='REFR'] [hl7:procedure [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.4.1']]]

@typeCode

cs

1 … 1

F

REFR

@contextConductionInd

bl

0 … 1

F

true

Constraint contains only ID of the child procedure, which is fully described in a dedicated entry further down in the Procedure step section.

hl7:reference

0 … *

R

Reference to an external document, or to external procedures, e.g. concerning molecular pathology or genetic testing report

Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)

PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

6.2.6.5 Container in Specimen Procedure Step - 1.3.6.1.4.1.19376.1.3.10.9.22

6.2.6.5.1 Definition and purpose

This Supporting Content Module is usable in the Specimen Procedure Steps <entry>. It describes the properties of containers, in or on which the specimens are processed. The relations between container and specimen are described in the HL7 Specimen DAM.

HL7 DAM Specimen Release 1.

For Anatomic Pathology the CDA Content Modules "Material" and "ManufacturedMaterial" were modified under the (preliminary) OIDs 1.3.6.1.4.1.19376.1.3.10.9.23 and 1.3.6.1.4.1.19376.1.3.10.9.24

6.2.6.5.2 Specification and Example

Id 1.3.6.1.4.1.19376.1.3.10.9.22 Effective Date valid from 2016‑07‑29 12:09:33

Status Draft Version Label 2.0

Name CDASupplyContainerAPSR2 Display Name CDA Supply Container APSR2

Description

Template CDA Supply (prototype, directly derived from POCD_RM000040 MIF)

This entry describes the properties of a container (and its components) which holds a specimen. It is usable within a Specimen Procedure Step entry and is repeatable in one procedure step for describing container components, too (e.g. container plus embedding medium, or microscopic slide plus mounting medium plus coverslip)

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.22

Label PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

Classification CDA Entry Level Template

Open/Closed Open (other than defined elements are allowed)

Used by / Uses

Used by 0 transactions and 4 templates, Uses 6 templates

Used by	as	Name	Version
1.3.6.1.4.1.19376.1.3.10.4.1	Containment	Specimen Procedure Step (2.0)	2016‑07‑08 13:20:59
	Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.3.10.4.1		Specimen Procedure Step (1.0)	2014‑07‑29 16:02:02
	Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.8.1.2.6		Procedure Steps Section (2.0)	2014‑05‑13 19:33:12
1.3.6.1.4.1.19376.1.8.1.1.1		Anatomic Pathology Structured Report Content Module (2.0)	2014‑05‑13 11:57:57
Uses	as	Name	Version
1.3.6.1.4.1.19376.1.3.10.9.1	Include	X Specimen Identified	2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.3.10.9.24	Containment	CDA ManufacturedProduct APSR2	2016‑09‑09 12:37:49
1.3.6.1.4.1.19376.1.3.3.1.7	Containment	Laboratory Performer (2017)	2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2	Containment	CDA author IHE	2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6	Containment	CDA Informant(Header&Body) APSR2 (2.0)	2016‑07‑08 11:22:58
2.16.840.1.113883.10.12.300	Containment	CDA Clinical Statement	2005‑09‑07

Relationship Specialization: template 2.16.840.1.113883.10.12.309 (2005‑09‑07)

Example

example for use case #1, grossing and embedding

Item DT Card Conf Description Label

hl7:supply

0 … *

R

PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

@classCode

cs

1 … 1

F

SPLY

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.3.10.9.22

hl7:id

II

0 … *

R

Container ID, coming from the LIS

PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

hl7:code

CD

0 … 1

R

PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

@code

CONF

0 … 1

F

74384-9

@codeSystem

0 … 1

F

2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)

@codeSystemName

0 … 1

F

LOINC

@displayName

0 … 1

F

Specimen container

hl7:text

ED

0 … 1

R

Textual description of the container (plus container components)

PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

Example

plastic tube

<text>plastic tube</text>

Example

Block

<text>paraffin block</text>

Example

Slide

<text>slide with mounting medium and coverslip</text>

hl7:statusCode

CS (required)

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (2014‑03‑26)

hl7:effectiveTime

SXCM_TS

0 … 1

R

PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

hl7:quantity

PQ

0 … 1

R

PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

hl7:expectedUseTime

IVL_TS

0 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

Included 0 … * R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)

hl7:specimen

0 … *

R

Required 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

@typeCode

cs

0 … 1

F

SPC

hl7:specimenRole

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified

@classCode

cs

0 … 1

F

SPEC

hl7:id

II

1 … 1

R

Specimen ID, coming from the LIS

PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified

hl7:product

1 … 1

M

Contains 1.3.6.1.4.1.19376.1.3.10.9.24 CDA ManufacturedProduct APSR2 (2016‑09‑09 12:37:49)

PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

where [@typeCode='PRD'] [not(@nullFlavor)]

@typeCode

cs

1 … 1

F

PRD

hl7:performer

0 … *

C

Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)

PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.3.1.7']]

hl7:author

0 … *

C

Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)

PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

where [hl7:author [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.2']]]

hl7:informant

0 … *

R

Contains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (2016‑07‑08 11:22:58)

PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.6']]

hl7:entryRelationship

0 … *

R

Contains 2.16.840.1.113883.10.12.300 CDA Clinical Statement (2005‑09‑07)

PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

where [@typeCode='COMP'] [hl7:act [hl7:templateId [@root='2.16.840.1.113883.10.12.301']] or
[hl7:templateId [@root='2.16.840.1.113883.10.12.302']] or
[hl7:templateId [@root='2.16.840.1.113883.10.12.303']] or
[hl7:templateId [@root='2.16.840.1.113883.10.12.304']] or
[hl7:templateId [@root='2.16.840.1.113883.10.12.305']] or
[hl7:templateId [@root='2.16.840.1.113883.10.12.306']] or
[hl7:templateId [@root='2.16.840.1.113883.10.12.307']] or
[hl7:templateId [@root='2.16.840.1.113883.10.12.308']] or
[hl7:templateId [@root='2.16.840.1.113883.10.12.309']]]

@typeCode

cs

1 … 1

F

COMP

@contextConductionInd

bl

0 … 1

F

true

@inversionInd

bl

0 … 1

@negationInd

bl

0 … 1

hl7:sequenceNumber

INT

0 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

hl7:seperatableInd

BL

0 … 1

PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

6.2.6.6 Informant – 1.3.6.1.4.1.19376.1.8.1.4.6

6.2.6.6.1 Definition and purpose

This Content Module is usable in the CDA header, in a <section> and within an <entry>.

It describes a person having provided some piece of relevant information for the document.

A <ClinicalDocument> or a <section> or any kind of act below an <entry>, MAY have zero or more informant.

6.2.6.6.2 Specification and Example

Id 1.3.6.1.4.1.19376.1.8.1.4.6 Effective Date valid from 2016‑07‑08 11:22:58

Status Draft Version Label 2.0

Name CDAinformantHeaderBodyAPSR2 Display Name CDA Informant(Header&Body) APSR2

Description

Template CDA Informant Body (prototype, directly derived from POCD_RM000040 MIF)

   
An informant is either an assignedEntity (a professional participating to the healthcare process, and who was assigned a defined role in that process) or a relatedEntity (a person who knows the patient and has provided relevant information concerning the patient). Hence the condition is either assignedEntity is present or relatedEntity is present.

Context Sibling nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.4.6

Label PaLM Suppl. APSR 2.0‑3: 6.3.6.5 Informant

Classification Template type not specified

Open/Closed Open (other than defined elements are allowed)

Used by / Uses

Used by 0 transactions and 32 templates, Uses 2 templates

Used by	as	Name	Version
1.3.6.1.4.1.19376.1.3.10.4.2	Containment	TNM Stage Observation (2.0)	2014‑05‑13 15:45:13
1.3.6.1.4.1.19376.1.3.10.4.1		Specimen Procedure Step (1.0)	2014‑07‑29 16:02:02
	Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.3.10.4.3	Containment	ICD-O-3 Typing and Grading Observation (2.0)	2015‑11‑29 17:03:18
1.3.6.1.4.1.19376.1.3.10.4.4	Containment	Assessment Scales Observation for Scoring Systems APSR2 (2.0)	2016‑10‑06 13:12:00
1.3.6.1.4.1.19376.1.3.10.9.22	Containment	CDA Supply Container APSR2 (2.0)	2016‑07‑29 12:09:33
1.3.6.1.4.1.19376.1.3.10.4.1		Specimen Procedure Step (2.0)	2016‑07‑08 13:20:59
	Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.8.1.2.6		Procedure Steps Section (2.0)	2014‑05‑13 19:33:12
1.3.6.1.4.1.19376.1.8.1.1.1		Anatomic Pathology Structured Report Content Module (2.0)	2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.3.10.9.25	Containment	TNM T-Observation (2.0)	2014‑12‑02 15:54:17
1.3.6.1.4.1.19376.1.3.10.9.26	Containment	TNM N-Observation (2.0)	2014‑12‑02 16:34:50
1.3.6.1.4.1.19376.1.3.10.9.27	Containment	TNM M-Observation (2.0)	2014‑12‑02 16:32:30
1.3.6.1.4.1.19376.1.3.10.9.28	Containment	TNM Grading (2.0)	2015‑11‑15 13:01:18
1.3.6.1.4.1.19376.1.3.10.9.29	Containment	TNM R-status (2.0)	2015‑06‑30 13:38:30
1.3.6.1.4.1.19376.1.3.10.9.30	Containment	TNM a (2.0)	2015‑06‑22 15:13:46
1.3.6.1.4.1.19376.1.3.10.9.31	Containment	TNM r (2.0)	2015‑06‑22 17:38:42
1.3.6.1.4.1.19376.1.3.10.9.32	Containment	TNM y (2.0)	2015‑06‑22 17:28:17
1.3.6.1.4.1.19376.1.3.10.9.33	Containment	TNM Serum tumor markers (2.0)	2015‑11‑06 14:28:44
1.3.6.1.4.1.19376.1.3.10.9.34	Containment	TNM Lymphatic Invasion (2.0)	2015‑11‑16 14:01:58
1.3.6.1.4.1.19376.1.3.10.9.35	Containment	TNM Venous Invasion (2.0)	2015‑11‑16 13:40:28
1.3.6.1.4.1.19376.1.3.10.9.36	Containment	TNM Perineural Invasion (2.0)	2015‑11‑11 16:13:40
1.3.6.1.4.1.19376.1.3.10.9.37	Containment	TNM Number of nodes (2.0)	2014‑12‑02 16:48:36
1.3.6.1.4.1.19376.1.3.10.9.43	Containment	Assessment Scoring Item APSR 2.0 (2.0)	2016‑10‑11 10:26:17
1.3.6.1.4.1.19376.1.3.10.9.42		Assessment Scoring System APSR 2.0 (2.0)	2016‑10‑10 11:33:36
1.3.6.1.4.1.19376.1.8.1.3.6	Containment	Problem Organizer (2.0)	2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.3.10.3.1		Additional Specified Observation Section (2.0)	2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.2.1		Clinical Information Section (2.0)	2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2		Intraoperative Observation Section (2.0)	2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3		Macroscopic Observation Section (2.0)	2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4		Microscopic Observation Section (2.0)	2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5		Diagnostic Conclusion Section (2.0)	2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.4.10	Containment	Embedded Image IHE	2016‑06‑22 16:08:01
1.3.6.1.4.1.19376.1.8.1.4.9		AP Observation Entry (2.0)	2014‑05‑14 17:09:54
	Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
Uses	as	Name	Version
2.16.840.1.113883.10.12.153	Containment	CDA AssignedEntity	2005‑09‑07
2.16.840.1.113883.10.12.316	Containment	CDA RelatedEntity	2005‑09‑07

Relationship Adaptation: template 2.16.840.1.113883.10.12.319 (2005‑09‑07)

Example

Item DT Card Conf Description Label

@typeCode

cs

0 … 1

F

INF

@contextControlCode

cs

0 … 1

F

OP

hl7:templateId

II

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.5 Informant

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.8.1.4.6

Choice

0 … 1

The

informant is either an assignedEntity (i.e. a person playing an identified role in the process of care) or a relatedEntity

(a person related to the patient)

Elements to choose from:

hl7:assignedEntity containing template 2.16.840.1.113883.10.12.153 CDA AssignedEntity (2005‑09‑07)
hl7:relatedEntity containing template 2.16.840.1.113883.10.12.316 CDA RelatedEntity (2005‑09‑07)

hl7:assignedEntity

0 … 1

C

Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (2005‑09‑07)

PaLM Suppl. APSR 2.0‑3: 6.3.6.5 Informant

hl7:relatedEntity

0 … 1

C

Contains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (2005‑09‑07)

PaLM Suppl. APSR 2.0‑3: 6.3.6.5 Informant

6.2.6.7 Additional participant in an entry - 1.3.6.1.4.1.19376.1.8.1.4.7

6.2.6.7.1 Definition and purpose

This Content Module is usable only within an <entry> element.

Additional participants MAY take part in any organizer as well as in any observation of an APSR. These participants MAY be any of these 4:

Validator: This is the same participation as Content Validator in the header of the report: a pathologist having verified the content (of this particular subset of results).
Device: A device used to produce this particular subset of results.
Responsible: The director of a laboratory (described in a performer element at the same level) who produced this particular subset of results.
Transcriptionist: This is the same participation as dataEnterer in the header of the report: a staff who entered, possibly from dictation, this particular subset of results.

6.2.6.7.2 Specification and Example

Id 1.3.6.1.4.1.19376.1.8.1.4.7 Effective Date valid from 2016‑07‑12 18:44:06

Status Draft Version Label

Name AdditionalParticipantAPSR Display Name Additional participant in an entry APSR (Body)

Description Template CDA Participant (Body) (prototype, directly derived from POCD_RM000040 MIF)

Label PaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant

Classification CDA Entry Level Template

Open/Closed Open (other than defined elements are allowed)

Used by / Uses

Used by 0 transactions and 18 templates, Uses 2 templates

Used by	as	Name	Version
1.3.6.1.4.1.19376.1.3.10.4.2	Containment	TNM Stage Observation (2.0)	2014‑05‑13 15:45:13
1.3.6.1.4.1.19376.1.3.10.4.1		Specimen Procedure Step (1.0)	2014‑07‑29 16:02:02
1.3.6.1.4.1.19376.1.3.10.4.3	Containment	ICD-O-3 Typing and Grading Observation (2.0)	2015‑11‑29 17:03:18
1.3.6.1.4.1.19376.1.3.10.4.4	Containment	Assessment Scales Observation for Scoring Systems APSR2 (2.0)	2016‑10‑06 13:12:00
1.3.6.1.4.1.19376.1.3.10.9.26	Containment	TNM N-Observation (2.0)	2014‑12‑02 16:34:50
1.3.6.1.4.1.19376.1.3.10.9.27	Containment	TNM M-Observation (2.0)	2014‑12‑02 16:32:30
1.3.6.1.4.1.19376.1.3.10.9.37	Containment	TNM Number of nodes (2.0)	2014‑12‑02 16:48:36
1.3.6.1.4.1.19376.1.3.10.9.43	Containment	Assessment Scoring Item APSR 2.0 (2.0)	2016‑10‑11 10:26:17
1.3.6.1.4.1.19376.1.3.10.9.42		Assessment Scoring System APSR 2.0 (2.0)	2016‑10‑10 11:33:36
1.3.6.1.4.1.19376.1.8.1.3.6	Containment	Problem Organizer (2.0)	2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.3.10.3.1		Additional Specified Observation Section (2.0)	2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.1.1		Anatomic Pathology Structured Report Content Module (2.0)	2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.1		Clinical Information Section (2.0)	2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2		Intraoperative Observation Section (2.0)	2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3		Macroscopic Observation Section (2.0)	2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4		Microscopic Observation Section (2.0)	2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5		Diagnostic Conclusion Section (2.0)	2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.4.9	Containment	AP Observation Entry (2.0)	2014‑05‑14 17:09:54
	Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
Uses	as	Name	Version
2.16.840.1.113883.10.12.315	Containment	CDA Device	2005‑09‑07
2.16.840.1.113883.10.12.313	Containment	CDA PlayingEntity	2005‑09‑07

Relationship Adaptation: template 2.16.840.1.113883.10.12.321 (2005‑09‑07)

Example

generated example

<templateId root="1.3.6.1.4.1.19376.1.8.1.4.7"/><time/><participantRole classCode="ROL"> <id root="1.2.3.999" extension="--example only--"/> <addr>addr</addr> <telecom value="tel:+1-12345678"/>  </participantRole>

Item DT Card Conf Description Label

@typeCode

cs

1 … 1

R

participant[@participationType="AUTHEN"
or @participationType="DEV"
or @participationType="RESP"
or @participationType="ENT"]

CONF

The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.10901 ParticipationType (2014‑03‑26)

@contextControlCode

cs

0 … 1

F

OP

hl7:templateId

II

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.8.1.4.7

hl7:time

TS

0 … 1

R

PaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant

hl7:participantRole

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant

@classCode

cs

0 … 1

F

ROL

hl7:id

II

0 … *

R

PaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant

hl7:addr

AD

0 … *

R

PaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant

hl7:telecom

TEL

0 … *

R

PaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant

Choice

0 … 1

Elements to choose from:

hl7:playingDevice containing template 2.16.840.1.113883.10.12.315 CDA Device (2005‑09‑07)
hl7:playingEntity containing template 2.16.840.1.113883.10.12.313 CDA PlayingEntity (2005‑09‑07)

Constraint

If the participationType is DEV, then the playingDevice sub-element SHALL be present and the playingEntity sub-element SHALL NOT be present.

In all other cases the playingDevice sub-element SHALL NOT be present and the playingEntity sub-element SHALL be present.

hl7:playingDevice

0 … 1

C

Contains 2.16.840.1.113883.10.12.315 CDA Device (2005‑09‑07)

PaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant

Constraint

When the participant is a device at least one of the sub-elements code

, softwareName and

manufacturerModelName SHALL be present.

hl7:playingEntity

0 … 1

C

Contains 2.16.840.1.113883.10.12.313 CDA PlayingEntity (2005‑09‑07)

PaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant

Constraint only name(s) SHALL be given

6.2.6.8 Problem Organizer – 1.3.6.1.4.1.19376.1.8.1.4.8

6.2.6.8.1 Definition and purpose

This Content Module is usable as only <entry> within any Section module except Procedure steps <section>.

The problem organizer groups the battery of observations together with embedded images performed to investigate on a single problem identified on a specimen or group of specimens. If a Problem cannot be addressed specifically the Problem organizer allows also the grouping around one specimen.

6.2.6.8.2 Specification and Example

1.3.6.1.4.1.19376.1.8.1.4.8/dynamic

6.2.6.9 AP Anatomic pathology Observation template – 1.3.6.1.4.1.19376.1.8.1.4.9

6.2.6.9.1 Definition and purpose

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.

6.2.6.9.2 Specification and Example

Id 1.3.6.1.4.1.19376.1.8.1.4.9 Effective Date valid from 2014‑05‑14 17:09:54

Status Draft Version Label 2.0

Name APObservationEntry Display Name AP Observation Entry

Description

This content module is usable within a Problem organizer.

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

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.

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.4.9

Label PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

Classification CDA Entry Level Template

Open/Closed Open (other than defined elements are allowed)

Used by / Uses

Used by 0 transactions and 9 templates, Uses 10 templates

Used by	as	Name	Version
1.3.6.1.4.1.19376.1.8.1.3.6	Containment	Problem Organizer (2.0)	2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.3.10.3.1		Additional Specified Observation Section (2.0)	2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.1.1		Anatomic Pathology Structured Report Content Module (2.0)	2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.1		Clinical Information Section (2.0)	2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2		Intraoperative Observation Section (2.0)	2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3		Macroscopic Observation Section (2.0)	2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4		Microscopic Observation Section (2.0)	2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5		Diagnostic Conclusion Section (2.0)	2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.4.9	Containment	AP Observation Entry (2.0)	2014‑05‑14 17:09:54
	Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
Uses	as	Name	Version
1.3.6.1.4.1.19376.1.3.3.1.7	Containment	Laboratory Performer (2017)	2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2	Containment	CDA author IHE	2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6	Containment	CDA Informant(Header&Body) APSR2 (2.0)	2016‑07‑08 11:22:58
1.3.6.1.4.1.19376.1.8.1.4.7	Containment	Additional participant in an entry APSR (Body)	2016‑07‑12 18:44:06
1.3.6.1.4.1.19376.1.8.1.4.9	Containment	AP Observation Entry (2.0)	2014‑05‑14 17:09:54
1.3.6.1.4.1.19376.1.8.1.4.10	Containment	Embedded Image IHE	2016‑06‑22 16:08:01
2.16.840.1.113883.10.12.307	Containment	CDA RegionOfInterest	2005‑09‑07
1.3.6.1.4.1.19376.1.5.3.1.4.2	Containment	IHE Comment Entry (2014)	2013‑12‑20
1.3.6.1.4.1.19376.1.3.10.9.1	Include	X Specimen Identified	2014‑12‑22 15:54:30
2.16.840.1.113883.10.12.324	Containment	CDA Reference	2005‑09‑07

Relationship Specialization: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)

Example

Observation example for use case #1, estrogen receptor

Item DT Card Conf Description Label

hl7:observation

0 … *

R

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

@classCode

cs

1 … 1

F

OBS

@moodCode

cs

1 … 1

F

EVN

@negationInd

bl

0 … 1

hl7:templateId

II

1 … 1

M

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.8.1.4.9

hl7:id

II

0 … *

R

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

hl7:code

CE (extensible)

1 … 1

M

The Anatomic pathology observation code should be taken from a reference terminology, preferably the LOINC terminology. National terminologies may be used.

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

@code

CONF

1 … 1

F

each_code_for_observable_entities_or_a_specific_procedure

@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

see_above

Example <code code="59847-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Histology and Behavior ICD-O-3"/>

hl7:text

ED

0 … 1

R

Narrative text about the observation

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

hl7:statusCode

CS (required)

1 … 1

M

The 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.

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

CONF

The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 (DYNAMIC)

Error: Cannot find value set "1.3.6.1.4.1.19376.1.3.11.2"

hl7:effectiveTime

IVL_TS

1 … 1

M

Date and time the observation has been made

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

hl7:value

ANY

0 … *

R

Observation values using the appropriate data type.

Numeric results use data type PQ, which includes the unit. The result is absent in case of ‘aborted’ observation.

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

Constraint The default data type, cardinalities and value set for the <value> element are dependant on the type of observation.

CONF

The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.11 AP Observation (2015‑11‑22 12:20:34)

Example

for observation on tumor type

<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"/>

hl7:interpretationCode

CE (extensible)

0 … 1

R

One or more codes interpreting the result, expressed with ObservationInterpretation vocabulary (e.g., H = high, L = low).

This element may be coded with other values than those of the ObservationInterpretation vocabulary, given that the coding strength is CWE (coded with exceptions).

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

CONF

The value of @code should be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)

hl7:methodCode

CE (extensible)

0 … 1

R

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

CONF

The value of @code should be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (2014‑03‑26)

hl7:performer

II

0 … 1

C

Performing lab

Source: PaLM TF-3: 6.3.2.20

Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.3.1.7']]

Constraint The performing laboratory is present at this level only if this particular observation was performed by a (subcontractor) laboratory distinct from the one issuing the rest of the observations in this organizer.

hl7:author

II

0 … *

C

Author

   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 (2016‑06‑21 14:02:11)

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

where [hl7:author [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.2']]]

hl7:informant

II

0 … *

R

Informant

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 (2016‑07‑08 11:22:58)

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.6']]

hl7:participant

II

0 … *

R

Additional 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) (2016‑07‑12 18:44:06)

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.7']]

hl7:entryRelationship

0 … *

R

Sub-Observation

The result obtained for an observation may lead to an additional AP observation to refine this result. This sub-observation is again an Anatomic Pathology Observation.

   
       
Source: Source: PaLM TF Suppl. APSR 2.0-3
   : 6.3.6.7

Contains 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54)

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

where [@typeCode='COMP'] [hl7:observation [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.9']]]

@typeCode

cs

1 … 1

F

COMP

hl7:entryRelationship

0 … *

R

Embedded image.

This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest.

Source: PaLM TF Suppl. APSR 2.0-3 : 6.3.6.8

Contains 1.3.6.1.4.1.19376.1.8.1.4.10 Embedded Image IHE (2016‑06‑22 16:08:01)

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

where [@typeCode='COMP'] [hl7:observationMedia [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.10']]]

@typeCode

cs

1 … 1

F

COMP

hl7:entryRelationship

0 … *

R

Region of Interest

Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (2005‑09‑07)

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

where [@typeCode='COMP'] [hl7:regionOfInterest [hl7:templateId [@root='2.16.840.1.113883.10.12.307']]]

@typeCode

cs

1 … 1

F

COMP

Constraint This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest.
In the latter case by an entryRelationship @typeCode="SUBJ"

hl7:entryRelationship

0 … *

R

Annotation comment

Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20)

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

where [hl7:act [hl7:templateId [@root='2.16.840.1.113883.10.20.1.40'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.2']]]

@typeCode

cs

0 … 1

F

COMP

Included 1 … * M from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Specimen identification

Example

Example for specimen referencing

<specimen>  <specimenRole> <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="slide_A_1_PR"/> </specimenRole></specimen>

hl7:specimen

1 … *

M

Required 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

@typeCode

cs

0 … 1

F

SPC

hl7:specimenRole

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified

@classCode

cs

0 … 1

F

SPEC

hl7:id

II

1 … 1

R

Specimen ID, coming from the LIS

PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified

hl7:reference

0 … *

R

Reference to an external document, or to external observations, e.g. concerning molecular pathology or genetic testing report
Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

6.2.6.10 Embedded Image – 1.3.6.1.4.1.19376.1.8.1.4.10

6.2.6.10.1 Definition and purpose

This Content Module is usable within an <entry> element, in relationship with a display anchor carried in the referencedObject attribute of a <renderMultimedia> element in the <text> element of the <section> holding this <entry>.

The <observationMedia> element carries an image, embedded in B64. This element may be standalone, or encapsulated within a <regionOfInterest> element which defines an overlay shape to focus on a part of the image.

This <observationMedia> element embeds the image binary data, encoded in B64.

6.2.6.10.2 Specification and Example

Id 1.3.6.1.4.1.19376.1.8.1.4.10 Effective Date valid from 2016‑06‑22 16:08:01

Status Draft Version Label

Name EmbeddedImageIHE Display Name Embedded Image IHE

Description

Template CDA ObservationMedia (prototype, directly derived from POCD_RM000040 MIF)

This Content Module is usable within an <entry> element, in relationship with a display anchor carried in the referencedObject attribute of a <renderMultimedia> element in the <text> element of the <section> holding this <entry>.

The <observationMedia> element carries an image, embedded in B64. This element may be standalone, or encapsulated within a <regionOfInterest> element which defines an overlay shape to focus on a part of the image.

This <observationMedia> element embeds the image binary data, encoded in B64.

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.4.10

Label PaLM TF‑3: 6.3.4.14 Embedded image

Classification CDA Entry Level Template

Open/Closed Open (other than defined elements are allowed)

Used by / Uses

Used by 0 transactions and 9 templates, Uses 5 templates

Used by	as	Name	Version
1.3.6.1.4.1.19376.1.8.1.3.6	Containment	Problem Organizer (2.0)	2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.3.10.3.1		Additional Specified Observation Section (2.0)	2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.1.1		Anatomic Pathology Structured Report Content Module (2.0)	2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.1		Clinical Information Section (2.0)	2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2		Intraoperative Observation Section (2.0)	2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3		Macroscopic Observation Section (2.0)	2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4		Microscopic Observation Section (2.0)	2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5		Diagnostic Conclusion Section (2.0)	2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.4.9	Containment	AP Observation Entry (2.0)	2014‑05‑14 17:09:54
	Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
Uses	as	Name	Version
1.3.6.1.4.1.19376.1.3.10.9.1	Include	X Specimen Identified	2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.3.3.1.7	Containment	Laboratory Performer (2017)	2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2	Containment	CDA author IHE	2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6	Containment	CDA Informant(Header&Body) APSR2 (2.0)	2016‑07‑08 11:22:58
1.3.6.1.4.1.19376.1.5.3.1.4.2	Containment	IHE Comment Entry (2014)	2013‑12‑20

Relationship Specialization: template 2.16.840.1.113883.10.12.304 (2005‑09‑07)

Example

generated example

Item DT Card Conf Description Label

hl7:observationMedia

0 … *

R

Embedded Image

PaLM TF‑3: 6.3.4.14 Embedded image

@classCode

cs

1 … 1

F

OBS

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

II

1 … 1

M

PaLM TF‑3: 6.3.4.14 Embedded image

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.8.1.4.10

hl7:id

II

0 … *

R

   The ID attribute is pointed to by the anchor in the referencedObject attribute of a <renderMultimedia> element in the <text> element of the <section> holding this <entry>.

PaLM TF‑3: 6.3.4.14 Embedded image

hl7:value

1 … 1

R

PaLM TF‑3: 6.3.4.14 Embedded image

@representation

cs

1 … 1

F

B64

@mediaType

cs

1 … 1

R

The mediaType attribute specifies the type of media/application to be used to display the image. For instance ‘image/gif’ or ‘image/jpeg’.

CONF

The value of @mediaType shall be drawn from value set 2.16.840.1.113883.1.11.14824 MediaType (DYNAMIC)

Constraint The <value> element contains the image encoded in Base 64. This is indicated by the value “B64”of attribute representation.

Included 1 … 1 M from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)

hl7:specimen

1 … 1

M

Required 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

@typeCode

cs

0 … 1

F

SPC

hl7:specimenRole

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified

@classCode

cs

0 … 1

F

SPEC

hl7:id

II

1 … 1

R

Specimen ID, coming from the LIS

PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified

hl7:performer

0 … *

C

Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)

PaLM TF‑3: 6.3.4.14 Embedded image

where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.3.1.7']]

hl7:author

0 … *

C

Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)

PaLM TF‑3: 6.3.4.14 Embedded image

where [hl7:author [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.2']]]

hl7:informant

0 … *

R

Contains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (2016‑07‑08 11:22:58)

PaLM TF‑3: 6.3.4.14 Embedded image

where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.6']]

hl7:entryRelationship

0 … *

R

Comment on this image.

Source: PCC TF-2: 6.3.4.6
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20)

PaLM TF‑3: 6.3.4.14 Embedded image

where [@typeCode='SUBJ'] [hl7:act [hl7:templateId [@root='2.16.840.1.113883.10.20.1.40'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.2']]]

@typeCode

cs

1 … 1

F

SUBJ

@inversionInd

bl

0 … 1

F

true

6.2.6.11 X Specimen Identified - 1.3.6.1.4.1.19376.1.3.10.9.1

This is an addendum to the reference text of APSR 2.0 GH

6.2.6.11.1 Definition and purpose

This Specimen Identification <entry> provides the machine-readable links between any type of observation or embedded image to the specimen, from which this observation or image is obtained. It is required when more than one specimen is documented at this level. It is only used in PaLM templates for Observations and Embedded images.

6.2.6.11.2 Specification and Example

Id 1.3.6.1.4.1.19376.1.3.10.9.1 Effective Date valid from 2014‑12‑22 15:54:30

Status Draft Version Label

Name SpecimenIdentified Display Name X Specimen Identified

Description

Template CDA Specimen (prototype, directly derived from POCD_RM000040 MIF)

Entry template for linking specimen ID to observation or to procedure.
Required in XD-LAB when more than one specimen is documented at this level.

Label PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified

Classification CDA Entry Level Template

Open/Closed Open (other than defined elements are allowed)

Used by / Uses

Used by 0 transactions and 32 templates, Uses 0 templates

Used by	as	Name	Version
1.3.6.1.4.1.19376.1.3.10.4.1	Include	Specimen Procedure Step (2.0)	2016‑07‑08 13:20:59
	Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.3.10.4.1		Specimen Procedure Step (1.0)	2014‑07‑29 16:02:02
	Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.8.1.2.6		Procedure Steps Section (2.0)	2014‑05‑13 19:33:12
1.3.6.1.4.1.19376.1.8.1.1.1		Anatomic Pathology Structured Report Content Module (2.0)	2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.3.10.4.2	Include	TNM Stage Observation (2.0)	2014‑05‑13 15:45:13
1.3.6.1.4.1.19376.1.3.10.4.3	Include	ICD-O-3 Typing and Grading Observation (2.0)	2015‑11‑29 17:03:18
1.3.6.1.4.1.19376.1.3.10.4.4	Include	Assessment Scales Observation for Scoring Systems APSR2 (2.0)	2016‑10‑06 13:12:00
1.3.6.1.4.1.19376.1.3.10.9.22	Include	CDA Supply Container APSR2 (2.0)	2016‑07‑29 12:09:33
1.3.6.1.4.1.19376.1.3.10.9.25	Include	TNM T-Observation (2.0)	2014‑12‑02 15:54:17
1.3.6.1.4.1.19376.1.3.10.9.26	Include	TNM N-Observation (2.0)	2014‑12‑02 16:34:50
1.3.6.1.4.1.19376.1.3.10.9.27	Include	TNM M-Observation (2.0)	2014‑12‑02 16:32:30
1.3.6.1.4.1.19376.1.3.10.9.28	Include	TNM Grading (2.0)	2015‑11‑15 13:01:18
1.3.6.1.4.1.19376.1.3.10.9.29	Include	TNM R-status (2.0)	2015‑06‑30 13:38:30
1.3.6.1.4.1.19376.1.3.10.9.34	Include	TNM Lymphatic Invasion (2.0)	2015‑11‑16 14:01:58
1.3.6.1.4.1.19376.1.3.10.9.35	Include	TNM Venous Invasion (2.0)	2015‑11‑16 13:40:28
1.3.6.1.4.1.19376.1.3.10.9.36	Include	TNM Perineural Invasion (2.0)	2015‑11‑11 16:13:40
1.3.6.1.4.1.19376.1.3.10.9.37	Include	TNM Number of nodes (2.0)	2014‑12‑02 16:48:36
1.3.6.1.4.1.19376.1.3.10.9.38	Include	ICD-O-3 Behavior (2.0)	2015‑12‑03 09:11:54
1.3.6.1.4.1.19376.1.3.10.9.39	Include	ICD-O-3 Differentiation (2.0)	2015‑12‑09 17:12:30
1.3.6.1.4.1.19376.1.3.10.9.40	Include	ICD-O-3 Morphology (1.0)	2015‑11‑29 15:45:48
1.3.6.1.4.1.19376.1.3.10.9.41	Include	ICD-O-3 Topography (2.0)	2015‑11‑16 18:38:07
1.3.6.1.4.1.19376.1.3.10.9.42	Include	Assessment Scoring System APSR 2.0 (2.0)	2016‑10‑10 11:33:36
1.3.6.1.4.1.19376.1.3.10.9.43	Include	Assessment Scoring Item APSR 2.0 (2.0)	2016‑10‑11 10:26:17
1.3.6.1.4.1.19376.1.8.1.3.6	Include	Problem Organizer (2.0)	2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.3.10.3.1		Additional Specified Observation Section (2.0)	2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.2.1		Clinical Information Section (2.0)	2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2		Intraoperative Observation Section (2.0)	2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3		Macroscopic Observation Section (2.0)	2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4		Microscopic Observation Section (2.0)	2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5		Diagnostic Conclusion Section (2.0)	2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.4.10	Include	Embedded Image IHE	2016‑06‑22 16:08:01
1.3.6.1.4.1.19376.1.8.1.4.9		AP Observation Entry (2.0)	2014‑05‑14 17:09:54
	Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check

Relationship Specialization: template 2.16.840.1.113883.10.12.322 (2005‑09‑07)

Example

<specimen typeCode="SPC"> <specimenRole classCode="SPEC"> <id root="1.2.3.999" extension="--example only, coming from the LIS--"/> </specimenRole></specimen>

Item DT Card Conf Description Label

hl7:specimen

0 … 1

R

Required 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

@typeCode

cs

0 … 1

F

SPC

hl7:specimenRole

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified

@classCode

cs

0 … 1

F

SPEC

hl7:id

II

1 … 1

R

Specimen ID, coming from the LIS

PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified

6.2.6.12 UICC/AJCC TNM Staging and Grading - 1.3.6.1.4.1.19376.1.3.10.4.2

This is an addendum to the reference text of APSR 2.0 GH

6.2.6.12.1 Definition and purpose

The UICC/AJCC TNM <entry> Content Modul contains in machine-readable form all the information concerning a TNM formula for a problem investigated. It is a constraint version of an AP Generic observation <entry> Content Module. It is usable within a Problem Organizer <entry> Content Module only.

This Content Module structures the machine-readable data, which characterize the staging and grading of a malignant Tumor according the UICC/AJCC regulations for the TNM system.

Figure 6.2.6.12.1-1 CDA-RMIM of the UICC/AJCC TNM <entry>

6.2.6.12.2 Specification and Example

Id 1.3.6.1.4.1.19376.1.3.10.4.2 Effective Date valid from 2014‑05‑13 15:45:13

Status Draft Version Label 2.0

Name TNMStageObservation Display Name TNM Stage Observation

Description Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF)

TNM stage with supporting categories

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.2

Label PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

Classification CDA Entry Level Template

Open/Closed Open (other than defined elements are allowed)

Used by / Uses

Used by 0 transactions and 1 template, Uses 17 templates

Used by	as	Name	Version
1.3.6.1.4.1.19376.1.3.10.4.1	Containment	Specimen Procedure Step (1.0)	2014‑07‑29 16:02:02
Uses	as	Name	Version
1.3.6.1.4.1.19376.1.3.3.1.7	Containment	Laboratory Performer (2017)	2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2	Containment	CDA author IHE	2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6	Containment	CDA Informant(Header&Body) APSR2 (2.0)	2016‑07‑08 11:22:58
1.3.6.1.4.1.19376.1.8.1.4.7	Containment	Additional participant in an entry APSR (Body)	2016‑07‑12 18:44:06
1.3.6.1.4.1.19376.1.3.10.9.1	Include	X Specimen Identified	2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.3.10.9.32	Containment	TNM y (2.0)	2015‑06‑22 17:28:17
1.3.6.1.4.1.19376.1.3.10.9.30	Containment	TNM a (2.0)	2015‑06‑22 15:13:46
1.3.6.1.4.1.19376.1.3.10.9.31	Containment	TNM r (2.0)	2015‑06‑22 17:38:42
1.3.6.1.4.1.19376.1.3.10.9.25	Containment	TNM T-Observation (2.0)	2014‑12‑02 15:54:17
1.3.6.1.4.1.19376.1.3.10.9.26	Containment	TNM N-Observation (2.0)	2014‑12‑02 16:34:50
1.3.6.1.4.1.19376.1.3.10.9.27	Containment	TNM M-Observation (2.0)	2014‑12‑02 16:32:30
1.3.6.1.4.1.19376.1.3.10.9.33	Containment	TNM Serum tumor markers (2.0)	2015‑11‑06 14:28:44
1.3.6.1.4.1.19376.1.3.10.9.34	Containment	TNM Lymphatic Invasion (2.0)	2015‑11‑16 14:01:58
1.3.6.1.4.1.19376.1.3.10.9.35	Containment	TNM Venous Invasion (2.0)	2015‑11‑16 13:40:28
1.3.6.1.4.1.19376.1.3.10.9.36	Containment	TNM Perineural Invasion (2.0)	2015‑11‑11 16:13:40
1.3.6.1.4.1.19376.1.3.10.9.28	Containment	TNM Grading (2.0)	2015‑11‑15 13:01:18
1.3.6.1.4.1.19376.1.3.10.9.29	Containment	TNM R-status (2.0)	2015‑06‑30 13:38:30

Relationship Specialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 (2014‑05‑14 17:09:54)

Example

Generated example

Item DT Card Conf Description Label

hl7:observation

0 … *

R

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

@classCode

cs

1 … 1

F

OBS

@moodCode

cs

1 … 1

F

ENV

@negationInd

bl

0 … 1

hl7:templateId

II

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.3.10.4.2

hl7:id

II

0 … *

R

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

hl7:code

CE (extensible)

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

CONF

@code shall be "21902-2"

@codeSystem shall be "2.16.840.1.113883.6.1"

@codeSystemName shall be "LOINC"

or

@code shall be "tnmStage"

@codeSystem shall be "1.2.276.0.76.3.1.131.1.5.1"

@codeSystemName shall be "DKG Coding Scheme"

@displayName shall be "tumor stage"

hl7:text

ED

0 … 1

R

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

Example <text> PATHOLOGIC STAGE (AJCC 7th Edition): IIA </text>

hl7:statusCode

CS (required)

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

Constraint

The 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 1.3.6.1.4.1.19376.1.3.11.2 (DYNAMIC)

Error: Cannot find value set "1.3.6.1.4.1.19376.1.3.11.2"

or

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (2014‑03‑26)

hl7:effectiveTime

IVL_TS

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

hl7:value

CD (extensible)

0 … 1

R

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

CONF

The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.46 UICC Stage (2017‑07‑21 10:43:31)

hl7:performer

II

0 … 1

C

Performing lab

Source: PaLM TF-3: 6.3.2.20

Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.3.1.7']]

Constraint The performing laboratory is present at this level only if this particular observation was performed by a (subcontractor) laboratory distinct from the one issuing the rest of the observations in this organizer.

hl7:author

II

0 … *

C

Author

   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 (2016‑06‑21 14:02:11)

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

where [hl7:author [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.2']]]

hl7:informant

II

0 … *

R

Informant

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 (2016‑07‑08 11:22:58)

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.6']]

hl7:participant

II

0 … *

R

Additional 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) (2016‑07‑12 18:44:06)

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.7']]

Included 1 … * M from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)

hl7:specimen

1 … *

M

Required 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

@typeCode

cs

0 … 1

F

SPC

hl7:specimenRole

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified

@classCode

cs

0 … 1

F

SPEC

hl7:id

II

1 … 1

R

Specimen ID, coming from the LIS

PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified

hl7:entryRelationship

0 … 1

R

staged after multimodal (neoadjuvant) therapy

Contains 1.3.6.1.4.1.19376.1.3.10.9.32 TNM y (2015‑06‑22 17:28:17)

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

where [@typeCode='SPRT'] [hl7:observation [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.9.32']]]

@typeCode

cs

1 … 1

F

SPRT

hl7:entryRelationship

0 … 1

R

first staged at autopsy
Contains 1.3.6.1.4.1.19376.1.3.10.9.30 TNM a (2015‑06‑22 15:13:46)

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

where [@typeCode='SPRT'] [hl7:observation [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.9.30']]]

@typeCode

cs

1 … 1

F

SPRT

hl7:entryRelationship

0 … 1

R

staged after relapse
Contains 1.3.6.1.4.1.19376.1.3.10.9.31 TNM r (2015‑06‑22 17:38:42)

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

where [@typeCode='SPRT'] [hl7:observation [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.9.31']]]

@typeCode

cs

1 … 1

F

SPRT

hl7:entryRelationship

1 … 1

R

T: T category of TNM

Contains 1.3.6.1.4.1.19376.1.3.10.9.25 TNM T-Observation (2014‑12‑02 15:54:17)

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

where [@typeCode='SPRT'] [hl7:observation [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.9.25']]]

@typeCode

cs

1 … 1

F

SPRT

hl7:entryRelationship

1 … 1

R

N: N category of TNM

Contains 1.3.6.1.4.1.19376.1.3.10.9.26 TNM N-Observation (2014‑12‑02 16:34:50)

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

where [@typeCode='SPRT'] [hl7:observation [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.9.26']]]

@typeCode

cs

1 … 1

F

SPRT

hl7:entryRelationship

0 … 1

R

M: M category of TNM

Contains 1.3.6.1.4.1.19376.1.3.10.9.27 TNM M-Observation (2014‑12‑02 16:32:30)

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

where [@typeCode='SPRT'] [hl7:observation [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.9.27']]]

@typeCode

cs

1 … 1

F

SPRT

hl7:entryRelationship

0 … 1

R

Serum tumor markers stage descriptor
Contains 1.3.6.1.4.1.19376.1.3.10.9.33 TNM Serum tumor markers (2015‑11‑06 14:28:44)

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

where [@typeCode='SPRT'] [hl7:observation [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.9.33']]]

@typeCode

cs

1 … 1

F

SPRT

hl7:entryRelationship

0 … 1

R

Descriptor for lymphatic invasion
Contains 1.3.6.1.4.1.19376.1.3.10.9.34 TNM Lymphatic Invasion (2015‑11‑16 14:01:58)

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

where [@typeCode='SPRT'] [hl7:observation [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.9.34']]]

@typeCode

cs

1 … 1

F

SPRT

hl7:entryRelationship

0 … 1

R

Descriptor for venous invasion

Contains 1.3.6.1.4.1.19376.1.3.10.9.35 TNM Venous Invasion (2015‑11‑16 13:40:28)

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

where [@typeCode='SPRT'] [hl7:observation [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.9.35']]]

@typeCode

cs

1 … 1

F

SPRT

hl7:entryRelationship

0 … 1

R

Descriptor for perineurial invasion

Contains 1.3.6.1.4.1.19376.1.3.10.9.36 TNM Perineural Invasion (2015‑11‑11 16:13:40)

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

where [@typeCode='SPRT'] [hl7:observation [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.9.36']]]

@typeCode

cs

1 … 1

F

SPRT

hl7:entryRelationship

1 … 1

R

TNM-Grading
Contains 1.3.6.1.4.1.19376.1.3.10.9.28 TNM Grading (2015‑11‑15 13:01:18)

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

where [@typeCode='SPRT'] [hl7:observation [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.9.28']]]

@typeCode

cs

1 … 1

F

SPRT

hl7:entryRelationship

0 … 1

R

Status of residual tumor
Contains 1.3.6.1.4.1.19376.1.3.10.9.29 TNM R-status (2015‑06‑30 13:38:30)

PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM

where [@typeCode='SPRT'] [hl7:observation [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.9.29']]]

@typeCode

cs

1 … 1

F

SPRT

6.2.6.13 ICD-O-3 Typing and Grading

This is an addendum to the reference text of APSR 2.0 GH

6.2.6.13.1 Definition and purpose

The ICD-O-3 Typing and Grading<entry> Content Modul contains in machine-readable form all the information concerning ICD-O-3 Typing and Grading for a problem investigated. It is a constraint version of an AP Generic observation <entry> Content Module. It is usable within a Problem Organizer <entry> Content Module only.

This Content Module structures the machine-readable data, which characterize the staging of a tumor or a systemic disease according the WHO regulations for the ICD-O-3 system.

Figure 6.2.6.13.1-1 CDA-RMIM of the ICD-O-3 <entry>

6.2.6.13.2 Specification and Example

Id 1.3.6.1.4.1.19376.1.3.10.4.3 Effective Date valid from 2015‑11‑29 17:03:18

Status Draft Version Label 2.0

Name ICD-O-3TypingGrading Display Name ICD-O-3 Typing and Grading Observation

Description Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF)

Entry template for observation on ICD-O-3 Typing and Grading

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.3

Label PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

Classification CDA Entry Level Template

Open/Closed Open (other than defined elements are allowed)

Used by / Uses

Used by 0 transactions and 0 templates, Uses 9 templates

Uses	as	Name	Version
1.3.6.1.4.1.19376.1.3.3.1.7	Containment	Laboratory Performer (2017)	2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2	Containment	CDA author IHE	2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6	Containment	CDA Informant(Header&Body) APSR2 (2.0)	2016‑07‑08 11:22:58
1.3.6.1.4.1.19376.1.8.1.4.7	Containment	Additional participant in an entry APSR (Body)	2016‑07‑12 18:44:06
1.3.6.1.4.1.19376.1.3.10.9.1	Include	X Specimen Identified	2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.3.10.9.38	Containment	ICD-O-3 Behavior (2.0)	2015‑12‑03 09:11:54
1.3.6.1.4.1.19376.1.3.10.9.39	Containment	ICD-O-3 Differentiation (2.0)	2015‑12‑09 17:12:30
1.3.6.1.4.1.19376.1.3.10.4.4	Containment	Assessment Scales Observation for Scoring Systems APSR2 (2.0)	2016‑10‑06 13:12:00
2.16.840.1.113883.10.12.324	Containment	CDA Reference	2005‑09‑07

Relationship Specialization: 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

Item DT Card Conf Description Label

hl7:observation

0 … 1

R

First four digits of Morphology axis code. A complete code consists of 6 digits (for morphology, behavior and grading), the latter both separated by "/" after the 4th digit in morphology.

Behavior and differentiation are coded as sub-observations

PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

@classCode

cs

1 … 1

F

OBS

@moodCode

cs

1 … 1

F

EVN

@negationInd

bl

0 … 1

hl7:templateId

II

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.3.10.4.3

hl7:id

II

0 … *

R

PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

hl7:code

CV (extensible)

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

CONF

@code shall be "31205-8"

@codeSystem shall be "2.16.840.1.113883.6.1"

@codeSystemName shall be "LOINC"

@displayName shall be "Histology ICD-O-3 Cancer"

or

@code shall be "397005006"

@codeSystem shall be "2.16.840.1.113883.6.96"

@codeSystemName shall be "SNOMED-CT"

@displayName shall be "WHO tumor classification (observable entity)"

hl7:statusCode

CS (required)

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

CONF

The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 (DYNAMIC)

Error: Cannot find value set "1.3.6.1.4.1.19376.1.3.11.2"

hl7:effectiveTime

IVL_TS

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

hl7:value

CD

1 … 1

R

First four digits of Morphology axis code

PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

CONF

The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.33 ICD-O-3 Morphology (2015‑11‑13 14:08:46)

Example

for use case #1: invasive breast cancer, NST, well differentiated

<value xsi:type="CD" code="8500" codeSystem="2.16.840.1.113883.6.43.1"/>

hl7:performer

II

0 … 1

C

Performing lab

Source: PaLM TF-3: 6.3.2.20

Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)

PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.3.1.7']]

hl7:author

II

0 … 1

C

Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)

PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

where [hl7:author [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.2']]]

hl7:informant

II

0 … *

R

Informant

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 (2016‑07‑08 11:22:58)

PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.6']]

hl7:participant

II

0 … *

R

Additional 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) (2016‑07‑12 18:44:06)

PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

where [hl7:templateId [@root='1.3.6.1.4.1.19376.1.8.1.4.7']]

Included 1 … * R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)

hl7:specimen

1 … *

R

Required 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

@typeCode

cs

0 … 1

F

SPC

hl7:specimenRole

1 … 1

M

PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified

@classCode

cs

0 … 1

F

SPEC

hl7:id

II

1 … 1

R

Specimen ID, coming from the LIS

PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified

hl7:entryRelationship

1 … 1

R

5th digit in the morphology axis code
Contains 1.3.6.1.4.1.19376.1.3.10.9.38 ICD-O-3 Behavior (2015‑12‑03 09:11:54)

PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

where [@typeCode='SPRT'] [hl7:observation [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.9.38']]]

@typeCode

cs

1 … 1

F

SPRT

hl7:entryRelationship

0 … 1

R

6th digit in the morphology axis code
Contains 1.3.6.1.4.1.19376.1.3.10.9.39 ICD-O-3 Differentiation (2015‑12‑09 17:12:30)

PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

where [@typeCode='SPRT'] [hl7:observation [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.9.39']]]

@typeCode

cs

1 … 1

F

SPRT

hl7:entryRelationship

0 … 1

R

optional grading by a scoring system, e.g. by means of the Elston-Ellis-Scoring-System in case of invasive breast cancer (ICD-O C50)

Contains 1.3.6.1.4.1.19376.1.3.10.4.4 Assessment Scales Observation for Scoring Systems APSR2 (2016‑10‑06 13:12:00)

PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

where [@typeCode='COMP'] [hl7:observation [hl7:templateId [@root='1.3.6.1.4.1.19376.1.3.10.4.4']]]

@typeCode

cs

1 … 1

F

COMP

hl7:reference

0 … *

R

Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)

PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

6.2.6.14 Assessment Scales for Scoring systems

This is an addendum to the reference text of APSR 2.0 GH

6.2.6.14.1 Definition and purpose

The Assessment Scales <entry> Content Modul contains in machine-readable form all the information concerning (semiquantitative) scoring systems often used for describing a tumor grading for a problem investigated. It is a constraint version of an AP Generic observation <entry> Content Module. It is usable within the ICD-O-3 Typing and Grading <entry> or within a Problem Organizer <entry> Content Module.

This Content Module structures the machine-readable data, which characterize the grading components of a tumor or a systemic disease according specific regulations.

Figure 6.2.6.14.1-1 CDA-RMIM of an Assessment Scales <entry>

6.2.6.14.2 Specification and Example

VOLUME 4 - VALUE SETS

Generic AP Observation Codes 1.3.6.1.4.1.19376.1.3.11.11

Id

1.3.6.1.4.1.19376.1.3.11.11

Effective Date

valid from 2015‑11‑22 12:20:34

Status

Draft

Version Label

Name

AP-Observation

Display Name

AP Observation

Description

Generic codes for AP Observations of all kind, including results of ancillary techniques (immunohistochemistry, in-situ-hybridization, other molecular methods)

Copyright

This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.

A valid code from one of the 12 code systems:

Code System Name	Code System Id	Code System Version	Flexibility
Logical Observation Identifier Names and Codes	2.16.840.1.113883.6.1		DYNAMIC
SNOMED Clinical Terms	2.16.840.1.113883.6.96		DYNAMIC
International Classification of Diseases for Oncology, version 3.	2.16.840.1.113883.6.43.1		DYNAMIC
ICD10	2.16.840.1.113883.6.3		DYNAMIC
TNM Edition8 UICC	2.16.840.1.113883.15.16		DYNAMIC
TNM Edition7 UICC	2.16.840.1.113883.15.6		DYNAMIC
TNM Edition6 UICC	2.16.840.1.113883.15.7		DYNAMIC
TNM Edition5 UICC	2.16.840.1.113883.15.8		DYNAMIC
Unified Code for Units of Measure	2.16.840.1.113883.6.8		DYNAMIC
Online Mendelian Inheritance in Man 1993	2.16.840.1.113883.6.174		DYNAMIC
DKG Coding scheme	1.2.276.0.76.3.1.131.1.5.1		DYNAMIC
localization codes for distant metastases	1.2.276.0.76.5.401		DYNAMIC

Problem type 1.3.6.1.4.1.19376.1.3.11.7

Id

1.3.6.1.4.1.19376.1.3.11.7

Effective Date

valid from 2016‑07‑11 09:52:19

Status

Draft

Version Label

Name

ProblemType

Display Name

Problem Type

Description

Values for the problem under investigation

Copyright

This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.

A valid code from the code system:

Code System Name	Code System Id	Code System Version
ICD10	2.16.840.1.113883.6.3

Or one of the following:

4 Source Code Systems

2.16.840.1.113883.6.3 - ICD10

2.16.840.1.113883.6.96 - SNOMED Clinical Terms

2.16.840.1.113883.5.6 - ActClass

2.16.840.1.113883.5.1008 - Null Flavor

Level/ Type	Code	Display Name	Code System
0‑L	115597007	Description of specimen character (procedure)	SNOMED Clinical Terms
0‑L	128462008	Secondary malignant neoplastic disease (disorder)	SNOMED Clinical Terms
0‑L	367651003	Malignant neoplasm of primary, secondary, or uncertain origin (morphologic abnormality)	SNOMED Clinical Terms
0‑L	SPCOBS	specimen observation	ActClass
0‑L	3898006	Neoplasm, benign (morphologic abnormality)	SNOMED Clinical Terms
0‑L	109355002	Carcinoma in situ (disorder)	SNOMED Clinical Terms
0‑L	23583003	Inflammation (morphologic abnormality)	SNOMED Clinical Terms
0‑L	33359002	Degeneration (morphologic abnormality)	SNOMED Clinical Terms
0‑L	49601007	Disorder of cardiovascular system (disorder)	SNOMED Clinical Terms
0‑L	ASKU	asked but unknown	Null Flavor

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

Container Entity Class Type 1.3.6.1.4.1.19376.1.3.11.8

Id

1.3.6.1.4.1.19376.1.3.11.8

Effective Date

valid from 2016‑09‑08 11:55:11

Status

Draft

Version Label

Name

ContainerEntityClassTypePaLM

Display Name

ContainerEntityClassTypePaLM

Description

Types of Containers and their additives in Anatomic Pathology

Copyright

This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.

2 Source Code Systems

2.16.840.1.113883.6.96 - SNOMED Clinical Terms

1.2.840.10008.2.16.4 - DICOM Controlled Terminology

Level/ Type	Code	Display Name	Code System
0‑L	434746001	Specimen vial (physical object)	SNOMED Clinical Terms
0‑L	434464009	Tissue cassette (physical object)	SNOMED Clinical Terms
0‑L	434708008	Tissue cassette for microarray (physical object)	SNOMED Clinical Terms
0‑L	433466003	Microscope slide (physical object)	SNOMED Clinical Terms
0‑S	433453003	Specimen container component (physical object)	SNOMED Clinical Terms
1‑S	430863003	Tissue embedding medium (substance)	SNOMED Clinical Terms
2‑L	311731000	Paraffin wax (substance)	SNOMED Clinical Terms
2‑L	433469005	Frozen section embedding medium (substance)	SNOMED Clinical Terms
2‑L	61088005	Plastic (substance)	SNOMED Clinical Terms
2‑L	10249006	Agar (substance)	SNOMED Clinical Terms
2‑L	65345002	Epoxy resin (substance)	SNOMED Clinical Terms
2‑L	427811002	Polymethyl methacrylate (substance)	SNOMED Clinical Terms
1‑L	433472003	Microscope slide coverslip (physical object)	SNOMED Clinical Terms
1‑L	430862008	Microscope slide mounting medium (substance)	SNOMED Clinical Terms
0‑S	CID8101	Container type	DICOM Controlled Terminology
1‑L	A-01024	Specimen vial	DICOM Controlled Terminology
1‑L	A-0101B	Microscope slide	DICOM Controlled Terminology
1‑L	A-01023	Specimen container	DICOM Controlled Terminology
1‑L	A-01021	Electron microscopy grid	DICOM Controlled Terminology
1‑L	A-01025	Specimen well	DICOM Controlled Terminology
0‑S	CID8114	Fixatives	DICOM Controlled Terminology
0‑S	CID8102	Container Component Types	DICOM Controlled Terminology
0‑S	CID8115	Specimen Embedding Media	DICOM Controlled Terminology

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

Procedure (target) site 1.3.6.1.4.1.19376.1.3.11.9

Id

1.3.6.1.4.1.19376.1.3.11.9

Effective Date

valid from 2016‑06‑01 18:46:15

Status

Draft

Version Label

Name

ProcedureSite

Display Name

Procedure Site

Description

Target sites of specimen processing procedures

Copyright

This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.

2 Source Code Systems

2.16.840.1.113883.6.96 - SNOMED Clinical Terms

1.2.840.10008.2.16.4 - DICOM Controlled Terminology

Level/ Type	Code	Display Name	Code System	Description
0‑L	309050000	Body substance sample	SNOMED Clinical Terms	all children of "Body substance sample"
0‑L	309051001	Body fluid sample	SNOMED Clinical Terms
0‑S	430856003	Tissue section (specimen)	SNOMED Clinical Terms
1‑L	441652008	Formalin-fixed paraffin-embedded tissue specimen	SNOMED Clinical Terms
1‑L	16214131000119104	Frozen tissue section sample (specimen)	SNOMED Clinical Terms
0‑S	CID8103	Anatomic Pathology Specimen Types	DICOM Controlled Terminology
1‑L	G-843A	Gross specimen	DICOM Controlled Terminology
1‑L	G-843B	Core sample of tissue block	DICOM Controlled Terminology
1‑L	G-843C	Tissue spot	DICOM Controlled Terminology
1‑L	G-803C	Smear sample	DICOM Controlled Terminology
1‑L	T-1A404	Touch preparation cytologic material	DICOM Controlled Terminology
1‑L	T-1A403	Liquid based cytologic material	DICOM Controlled Terminology
1‑L	G-8003	Aspirate	DICOM Controlled Terminology
0‑L	48469005	Cytologic material (specimen)	SNOMED Clinical Terms

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

Specimen collection and processing 1.3.6.1.4.1.19376.1.3.11.10

Id

1.3.6.1.4.1.19376.1.3.11.10

Effective Date

valid from 2016‑05‑31 15:09:59

Status

Draft

Version Label

Name

SpecimenCollectionAndProcessing

Display Name

Specimen Collection and Processing

Description

Mixed Value set for Specimen collection and Processing

Copyright

This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.

5 Source Code Systems

2.16.840.1.113883.5.6 - ActClass

2.16.840.1.113883.6.96 - SNOMED Clinical Terms

1.2.276.0.76.5.464

1.2.840.10008.2.16.4 - DICOM Controlled Terminology

2.16.840.1.113883.6.4 - International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

Level/ Type	Code	Display Name	Code System
0‑S	SPECCOLLECT	Specimen collection	ActClass
1‑S	17636008	Specimen collection (procedure)	SNOMED Clinical Terms
2‑L	48635004	Fine needle biopsy (procedure)	SNOMED Clinical Terms
2‑S	86273004	Biopsy (procedure)	SNOMED Clinical Terms
3‑L	439336003	Brush biopsy (procedure)	SNOMED Clinical Terms
3‑L	53767003	Endoscopic biopsy (procedure)	SNOMED Clinical Terms
3‑L	8889005	Excisional biopsy (procedure)	SNOMED Clinical Terms
3‑S	277590007	Imaging guided biopsy (procedure)	SNOMED Clinical Terms
4‑L	442787002	Fine needle aspiration biopsy using imaging guidance (procedure)	SNOMED Clinical Terms
4‑L	277592004	Magnetic resonance imaging guided biopsy (procedure)	SNOMED Clinical Terms
4‑L	277667006	Ultrasound guided biopsy (procedure)	SNOMED Clinical Terms
4‑L	277666002	X-ray guided biopsy (procedure)	SNOMED Clinical Terms
3‑L	45681003	Staging operation involving incision, exploration and biopsy (procedure)	SNOMED Clinical Terms
3‑L	70871006	Incisional biopsy (procedure)	SNOMED Clinical Terms
3‑L	129249002	Needle biopsy (procedure)	SNOMED Clinical Terms
3‑L	119283008	Open biopsy (procedure)	SNOMED Clinical Terms
3‑L	68660007	Punch biopsy (procedure)	SNOMED Clinical Terms
3‑L	72342005	Shave biopsy (procedure)	SNOMED Clinical Terms
3‑L	274330002	Surgical biopsy (procedure)	SNOMED Clinical Terms
3‑L	50590007	Trephine biopsy (procedure)	SNOMED Clinical Terms
2‑S	65801008	Excision (procedure)	SNOMED Clinical Terms
3‑L	81723002	Amputation (procedure)	SNOMED Clinical Terms
3‑L	86743009	Local excision (procedure)	SNOMED Clinical Terms
3‑L	125571002	Lobectomy (procedure)	SNOMED Clinical Terms
3‑L	26007001	Hemi-excision (procedure)	SNOMED Clinical Terms
3‑L	38829003	Partial excision (procedure)	SNOMED Clinical Terms
3‑L	89540006	Segmental excision and ligation (procedure)	SNOMED Clinical Terms
3‑L	65854006	Reexcision (procedure)	SNOMED Clinical Terms
3‑S	62141006	Radical excision (procedure)	SNOMED Clinical Terms
4‑L	88088007	Radical excision with lymph node dissection (procedure)	SNOMED Clinical Terms
3‑L	79095000	Complete excision of organ (procedure)	SNOMED Clinical Terms
3‑L	370612006	Excision of neoplasm (procedure)	SNOMED Clinical Terms
3‑L	20418004	Wedge resection (procedure)	SNOMED Clinical Terms
2‑L	56757003	Scraping (procedure)	SNOMED Clinical Terms
1‑L	1-40...1-49	Biopsies without incision	1.2.276.0.76.5.464
1‑L	1-50...1-58	Biopsies with incision	1.2.276.0.76.5.464
1‑L	5-01...5-09	Surgical measures	1.2.276.0.76.5.464
1‑L	1-10...1-99	Diagnostic measures	1.2.276.0.76.5.464
1‑S	CID8109	all children of Specimen Collection Procedure	DICOM Controlled Terminology
1‑S	00...0Y	all children of 0	International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)
0‑S	SPCTRT	Specimen treatment	ActClass
1‑S	CID8110	all children of Specimen Sampling Procedures	DICOM Controlled Terminology
1‑S	CID8111	all children of Specimen Preparation Procedure	DICOM Controlled Terminology
1‑S	CID8112	all children of Specimen Stains	DICOM Controlled Terminology
1‑S	CID8113	all children of Specimen Preparation Steps	DICOM Controlled Terminology
1‑S	CID8114	all children of Specimen Fixatives	DICOM Controlled Terminology
1‑S	9265001	Specimen processing (procedure)	SNOMED Clinical Terms
2‑L	430854000	Touch preparation of specimen (procedure)	SNOMED Clinical Terms
2‑L	448938001	Preparation of smear (procedure)	SNOMED Clinical Terms
2‑L	77896007	Cytopathology procedure, cell block and smear preparation (procedure)	SNOMED Clinical Terms
2‑L	4064007	Specimen aliquoting (procedure)	SNOMED Clinical Terms
2‑L	8378006	Trimming (procedure)	SNOMED Clinical Terms
2‑L	73373003	Specimen centrifugation (procedure)	SNOMED Clinical Terms
2‑L	27872000	Specimen freezing (procedure)	SNOMED Clinical Terms
2‑L	104166004	Nucleic acid molecular isolation or extraction method (procedure)	SNOMED Clinical Terms
2‑S	13283003	Tissue processing technique (procedure)	SNOMED Clinical Terms
3‑L	27204007	Tissue frozen section technique, complete (procedure)	SNOMED Clinical Terms
3‑L	40923002	Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)	SNOMED Clinical Terms
4‑L	434472006	Sectioning of tissue block (procedure)	SNOMED Clinical Terms
4‑L	434475008	Step sectioning of tissue block (procedure)	SNOMED Clinical Terms
4‑L	434474007	Surface recutting of tissue block (procedure)	SNOMED Clinical Terms
4‑L	434479002	Core sampling of tissue block (procedure)	SNOMED Clinical Terms
4‑L	433454009	Microdissection of tissue specimen using laser (procedure)	SNOMED Clinical Terms
4‑L	702941008	Paraffin embedding (qualifier value)	SNOMED Clinical Terms
2‑S	127790008	Staining method (procedure)	SNOMED Clinical Terms
3‑L	406792001	Acid phosphatase stain method (procedure)	SNOMED Clinical Terms
3‑L	406901007	Neutrophil alkaline phosphatase stain method (procedure)	SNOMED Clinical Terms
3‑L	406902000	New fuchsin stain method (procedure)	SNOMED Clinical Terms
3‑L	406903005	Nile blue stain method (procedure)	SNOMED Clinical Terms
3‑L	406904004	Nitrazine yellow stain method (procedure)	SNOMED Clinical Terms
3‑L	117229004	Nonspecific esterase stain method (procedure)	SNOMED Clinical Terms
3‑L	406905003	Nuclear fast red stain method (procedure)	SNOMED Clinical Terms
3‑L	406906002	Orange G stain method (procedure)	SNOMED Clinical Terms
3‑L	406907006	Orange II stain method (procedure)	SNOMED Clinical Terms
3‑L	406908001	Page blue 83 stain method (procedure)	SNOMED Clinical Terms
3‑L	406909009	Page blue G-90 stain method (procedure)	SNOMED Clinical Terms
3‑L	406910004	Patent blue V sodium salt stain method (procedure)	SNOMED Clinical Terms
3‑L	406911000	Permethrin stain method (procedure)	SNOMED Clinical Terms
3‑L	406912007	Phloxin B stain method (procedure)	SNOMED Clinical Terms
3‑L	406913002	Ponceau 3R stain method (procedure)	SNOMED Clinical Terms
3‑L	406914008	Ponceau S stain method (procedure)	SNOMED Clinical Terms
3‑L	406915009	Ponceau xylidine stain method (procedure)	SNOMED Clinical Terms
3‑L	406916005	Pontamine sky blue 5BX stain method (procedure)	SNOMED Clinical Terms
3‑L	406900008	Naphthol yellow S stain method (procedure)	SNOMED Clinical Terms
3‑L	406899003	Naphthol green B stain method (procedure)	SNOMED Clinical Terms
3‑L	406898006	Naphthalene black 12B stain method (procedure)	SNOMED Clinical Terms
3‑L	117306005	Lawson-Van Gieson stain method (procedure)	SNOMED Clinical Terms
3‑L	406875003	Leishman stain method (procedure)	SNOMED Clinical Terms
3‑L	406876002	Light green SF stain method (procedure)	SNOMED Clinical Terms
3‑L	406877006	Lissamine fast red B stain method (procedure)	SNOMED Clinical Terms
3‑L	406878001	Lissamine fast yellow stain method (procedure)	SNOMED Clinical Terms
3‑L	406880007	Lissamine rhodamine stain method (procedure)	SNOMED Clinical Terms
3‑L	398507009	Malachite green stain method (procedure)	SNOMED Clinical Terms
3‑L	117218003	Mallory bleach stain method (procedure)	SNOMED Clinical Terms
3‑L	406890004	Martius yellow stain method (procedure)	SNOMED Clinical Terms
3‑L	406891000	Meldola blue stain method (procedure)	SNOMED Clinical Terms
3‑L	406892007	Metanil yellow stain method (procedure)	SNOMED Clinical Terms
3‑L	406893002	Methyl blue stain method (procedure)	SNOMED Clinical Terms
3‑L	406894008	Methyl orange stain method (procedure)	SNOMED Clinical Terms
3‑L	406895009	Methyl red stain method (procedure)	SNOMED Clinical Terms
3‑L	406896005	Methylene blue stain method (procedure)	SNOMED Clinical Terms
3‑L	406897001	Methylene violet stain (Bernthsen) method (procedure)	SNOMED Clinical Terms
3‑L	37926009	Microbial stain method (procedure)	SNOMED Clinical Terms
3‑L	406917001	Pontamine sky blue 6BX stain method (procedure)	SNOMED Clinical Terms
3‑L	406918006	Procion brilliant blue MRS stain method (procedure)	SNOMED Clinical Terms
3‑L	117326009	Quinacrine fluorescent stain method (procedure)	SNOMED Clinical Terms
3‑L	406936006	Sudan blue stain method (procedure)	SNOMED Clinical Terms
3‑L	406937002	Sunset yellow FCF stain method (procedure)	SNOMED Clinical Terms
3‑L	117031001	Supravital stain method (procedure)	SNOMED Clinical Terms
3‑L	406938007	Tartrazine stain method (procedure)	SNOMED Clinical Terms
3‑L	406939004	Thioflavine T stain method (procedure)	SNOMED Clinical Terms
3‑L	406940002	Thionine stain method (procedure)	SNOMED Clinical Terms
3‑L	406941003	Titan yellow stain method (procedure)	SNOMED Clinical Terms
3‑L	406942005	Tropaeolin O stain method (procedure)	SNOMED Clinical Terms
3‑L	406943000	Tropaeolin OO stain method (procedure)	SNOMED Clinical Terms
3‑L	406944006	Trypan blue stain method (procedure)	SNOMED Clinical Terms
3‑L	406945007	Vital new red stain method (procedure)	SNOMED Clinical Terms
3‑L	104249006	Vital stain method (procedure)	SNOMED Clinical Terms
3‑L	406946008	Water soluble aniline blue stain method (procedure)	SNOMED Clinical Terms
3‑L	406948009	Water soluble anthracene brown stain method (procedure)	SNOMED Clinical Terms
3‑L	406947004	Water soluble nigrosine stain method (procedure)	SNOMED Clinical Terms
3‑L	406949001	Waxoline blue stain method (procedure)	SNOMED Clinical Terms
3‑L	406950001	Xylene cyanol FF stain method (procedure)	SNOMED Clinical Terms
3‑L	406934009	Sudan black stain method (procedure)	SNOMED Clinical Terms
3‑L	406935005	Sudan black B stain method (procedure)	SNOMED Clinical Terms
3‑L	117030000	Sudan IV stain method (procedure)	SNOMED Clinical Terms
3‑L	406919003	Romanowsky stain method (procedure)	SNOMED Clinical Terms
3‑L	406920009	Rose bengal stain method (procedure)	SNOMED Clinical Terms
3‑L	406921008	Rosolic acid sodium salt stain method (procedure)	SNOMED Clinical Terms
3‑L	406922001	Saffron stain method (procedure)	SNOMED Clinical Terms
3‑L	117330007	Schmorl stain method (procedure)	SNOMED Clinical Terms
3‑L	117041003	Silver stain method (procedure)	SNOMED Clinical Terms
3‑L	406924000	Sirius red F3B stain method (procedure)	SNOMED Clinical Terms
3‑L	406925004	Solochrome azurine (BS) stain method (procedure)	SNOMED Clinical Terms
3‑L	406926003	Solochrome black 6B stain method (procedure)	SNOMED Clinical Terms
3‑L	406927007	Solochrome cyanine R stain method (procedure)	SNOMED Clinical Terms
3‑L	406928002	Solochrome dark blue stain method (procedure)	SNOMED Clinical Terms
3‑L	406929005	Soluble berlin blue stain method (procedure)	SNOMED Clinical Terms
3‑L	406930000	Spirit soluble aniline blue stain method (procedure)	SNOMED Clinical Terms
3‑L	406931001	Spirit soluble eosin stain method (procedure)	SNOMED Clinical Terms
3‑L	406932008	Spore stain method (procedure)	SNOMED Clinical Terms
3‑L	406933003	Sudan II stain method (procedure)	SNOMED Clinical Terms
3‑L	117029005	Sudan III stain method (procedure)	SNOMED Clinical Terms
3‑L	406874004	Lacmoid stain method (procedure)	SNOMED Clinical Terms
3‑L	406873005	Kenacid blue R stain method (procedure)	SNOMED Clinical Terms
3‑L	406818007	Bismark brown Y stain method (procedure)	SNOMED Clinical Terms
3‑L	406819004	Blue shade eosin stain method (procedure)	SNOMED Clinical Terms
3‑L	406820005	Brazilin stain method (procedure)	SNOMED Clinical Terms
3‑L	406821009	Brilliant cresyl blue stain method (procedure)	SNOMED Clinical Terms
3‑L	406822002	Brilliant crocein stain method (procedure)	SNOMED Clinical Terms
3‑L	406823007	Brilliant orange stain method (procedure)	SNOMED Clinical Terms
3‑L	406824001	Brilliant yellow stain method (procedure)	SNOMED Clinical Terms
3‑L	77281003	Calcofluor white stain (procedure)	SNOMED Clinical Terms
3‑L	406825000	Carminic acid stain method (procedure)	SNOMED Clinical Terms
3‑L	406826004	Carmoisine A stain method (procedure)	SNOMED Clinical Terms
3‑L	406827008	Celestine blue B stain method (procedure)	SNOMED Clinical Terms
3‑L	406828003	Chloroacetate esterase stain method (procedure)	SNOMED Clinical Terms
3‑L	406830001	Chromotrope 2R stain method (procedure)	SNOMED Clinical Terms
3‑L	406831002	Chrysoidine R stain method (procedure)	SNOMED Clinical Terms
3‑L	406832009	Chrysoidine Y stain method (procedure)	SNOMED Clinical Terms
3‑L	406833004	Cochineal stain method (procedure)	SNOMED Clinical Terms
3‑L	117055006	Congo red stain method (procedure)	SNOMED Clinical Terms
3‑L	406817002	Bismark brown R stain method (procedure)	SNOMED Clinical Terms
3‑L	406816006	Biebrich scarlet stain method (procedure)	SNOMED Clinical Terms
3‑L	406815005	Beta-glucuronidase stain method (procedure)	SNOMED Clinical Terms
3‑L	406793006	Albert's stain method (procedure)	SNOMED Clinical Terms
3‑L	117036006	Alcian blue stain method (procedure)	SNOMED Clinical Terms
3‑L	406794000	Alcohol soluble nigrosine stain method (procedure)	SNOMED Clinical Terms
3‑L	406795004	Alizarin blue S stain method (procedure)	SNOMED Clinical Terms
3‑L	406796003	Alizarin cyanine green stain method (procedure)	SNOMED Clinical Terms
3‑L	406797007	Alizarin red S stain method (procedure)	SNOMED Clinical Terms
3‑L	406798002	Alizarin yellow GG stain method (procedure)	SNOMED Clinical Terms
3‑L	406799005	Alizarin yellow R stain method (procedure)	SNOMED Clinical Terms
3‑L	406800009	Auramine stain method (procedure)	SNOMED Clinical Terms
3‑L	406801008	Azo black stain method (procedure)	SNOMED Clinical Terms
3‑L	406802001	Azocarmine G (GX) stain method (procedure)	SNOMED Clinical Terms
3‑L	406803006	Azophloxin stain method (procedure)	SNOMED Clinical Terms
3‑L	406804000	Azorubin S stain method (procedure)	SNOMED Clinical Terms
3‑L	406811001	Azure A stain method (procedure)	SNOMED Clinical Terms
3‑L	406812008	Azure B stain method (procedure)	SNOMED Clinical Terms
3‑L	406813003	Azure C stain method (procedure)	SNOMED Clinical Terms
3‑L	406814009	Benzo fast scarlet stain method (procedure)	SNOMED Clinical Terms
3‑L	406835006	Crystal ponceau stain method (procedure)	SNOMED Clinical Terms
3‑L	406836007	Curcumin stain method (procedure)	SNOMED Clinical Terms
3‑L	117298004	Cytopathology staining method (procedure)	SNOMED Clinical Terms
3‑L	406857004	Flagellar stain method (procedure)	SNOMED Clinical Terms
3‑L	406858009	Fluorescent stain method (procedure)	SNOMED Clinical Terms
3‑L	406863008	Fuchsin acid stain method (procedure)	SNOMED Clinical Terms
3‑L	117047004	Fuchsin basic stain method (procedure)	SNOMED Clinical Terms
3‑L	20543007	Fungus stain method (procedure)	SNOMED Clinical Terms
3‑L	406864002	Gallocyanine stain method (procedure)	SNOMED Clinical Terms
3‑L	422329009	Hall's bilirubin stain (procedure)	SNOMED Clinical Terms
3‑L	406865001	Hematein stain method (procedure)	SNOMED Clinical Terms
3‑L	108256005	Hematology staining procedure (procedure)	SNOMED Clinical Terms
3‑L	406867009	Immunofluorescent stain method (procedure)	SNOMED Clinical Terms
3‑L	406868004	Indigo carmine stain method (procedure)	SNOMED Clinical Terms
3‑L	406869007	Indophenol from naphthol stain method (procedure)	SNOMED Clinical Terms
3‑L	406870008	Insoluble berlin blue stain method (procedure)	SNOMED Clinical Terms
3‑L	406871007	Janus green B stain method (procedure)	SNOMED Clinical Terms
3‑L	406872000	Jenner-Giemsa stain method (procedure)	SNOMED Clinical Terms
3‑L	406856008	Field's stain method (procedure)	SNOMED Clinical Terms
3‑L	406855007	Feulgen reaction stain method (procedure)	SNOMED Clinical Terms
3‑L	406854006	Fat red 7B stain method (procedure)	SNOMED Clinical Terms
3‑L	406837003	Diamond black stain method (procedure)	SNOMED Clinical Terms
3‑L	406838008	Durazol red stain method (procedure)	SNOMED Clinical Terms
3‑L	406839000	Erie garnet stain method (procedure)	SNOMED Clinical Terms
3‑L	406840003	Eriochrome blue black SE stain method (procedure)	SNOMED Clinical Terms
3‑L	406841004	Erythrosin B stain method (procedure)	SNOMED Clinical Terms
3‑L	406842006	Erythrosin Y stain method (procedure)	SNOMED Clinical Terms
3‑L	406843001	Evans blue stain method (procedure)	SNOMED Clinical Terms
3‑L	406844007	Fast blue B salt stain method (procedure)	SNOMED Clinical Terms
3‑L	406845008	Fast blue BB salt stain method (procedure)	SNOMED Clinical Terms
3‑L	406846009	Fast blue RR salt stain method (procedure)	SNOMED Clinical Terms
3‑L	406847000	Fast garnet GBC salt stain method (procedure)	SNOMED Clinical Terms
3‑L	406848005	Fast green FCF stain method (procedure)	SNOMED Clinical Terms
3‑L	406849002	Fast red B salt stain method (procedure)	SNOMED Clinical Terms
3‑L	406850002	Fast red ITR stain method (procedure)	SNOMED Clinical Terms
3‑L	406851003	Fast red TR salt stain method (procedure)	SNOMED Clinical Terms
3‑L	406852005	Fast sulfon black F stain method (procedure)	SNOMED Clinical Terms
3‑L	406853000	Fast violet B salt stain method (procedure)	SNOMED Clinical Terms
3‑L	406979008	Ziehl-Neelsen stain method (procedure)	SNOMED Clinical Terms
3‑S	104210008	Hematoxylin and eosin stain method (procedure)	SNOMED Clinical Terms
4‑L	117239005	Harris regressive hematoxylin and eosin stain method (procedure)	SNOMED Clinical Terms
4‑L	117240007	Mayers progressive hematoxylin and eosin stain method (procedure)	SNOMED Clinical Terms
3‑L	80246006	Special stain, blood or bone marrow, explain by report (procedure)	SNOMED Clinical Terms
3‑L	117617002	Immunohistochemistry procedure (procedure)	SNOMED Clinical Terms
3‑L	384715000	Nucleic acid hybridization procedure (procedure)	SNOMED Clinical Terms

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

UICC/AJCC stage 1.3.6.1.4.1.19376.1.3.11.18

Id

1.3.6.1.4.1.19376.1.3.11.18

Effective Date

valid from 2015‑06‑23 16:43:02

Status

Draft

Version Label

Name

UICCstage

Display Name

UICC Stage (7ed)

Description

UICC Stages<br clear="none"/>

Source Code System

2.16.840.1.113883.15.6 - TNM Edition7 UICC

Level/ Type	Code	Display Name	Code System	Description
0‑L	okk	stage X	TNM Edition7 UICC	TX, N0, M0
0‑S	0	stage 0	TNM Edition7 UICC	Tis N0 M0
1‑L	0a	stage 0a	TNM Edition7 UICC	in C67 only
1‑L	0is	stage 0is	TNM Edition7 UICC	in C67 only
0‑S	I	stage I	TNM Edition7 UICC	organ dependent
2‑L	IA1	stage IA1	TNM Edition7 UICC	organ dependent<br clear="none"/>
2‑L	IA2	stage IA2	TNM Edition7 UICC	organ dependent<br clear="none"/>
1‑S	IB	stage IB	TNM Edition7 UICC	organ dependent
2‑L	IB1	stage IB1	TNM Edition7 UICC	organ dependent<br clear="none"/>
2‑L	IB2	stage IB2	TNM Edition7 UICC	organ dependent<br clear="none"/>
1‑L	IC	stage IC	TNM Edition7 UICC	organ dependent<br clear="none"/>
1‑L	IS	stage IS	TNM Edition7 UICC	in C62 only
0‑S	II	stage II	TNM Edition7 UICC	organ dependent<br clear="none"/>
2‑L	IIA	stage IIA	TNM Edition7 UICC	organ dependent<br clear="none"/> <br clear="none"/>
2‑L	IIA1	stage IIA1	TNM Edition7 UICC	organ dependent<br clear="none"/>
2‑L	IIA2	stage IIA2	TNM Edition7 UICC	organ dependent<br clear="none"/>
1‑L	IIB	stage IIB	TNM Edition7 UICC	organ dependent<br clear="none"/>
1‑L	IIC	stage IIC	TNM Edition7 UICC	organ dependent<br clear="none"/> <br clear="none"/>
0‑S	III	stage III	TNM Edition7 UICC	organ dependent<br clear="none"/>
1‑L	IIIA	stage IIIA	TNM Edition7 UICC	organ dependent<br clear="none"/>
1‑L	IIIB	stage IIIB	TNM Edition7 UICC	organ dependent<br clear="none"/> <br clear="none"/>
1‑L	IIIC	stage IIIC	TNM Edition7 UICC	organ dependent<br clear="none"/>
0‑S	IV	stage IV	TNM Edition7 UICC	each T, each N, M1
1‑L	IVA	stage IVA	TNM Edition7 UICC	organ dependent<br clear="none"/>
1‑L	IVB	stage IVB	TNM Edition7 UICC	organ dependent<br clear="none"/>
1‑L	IVC	stage IVC	TNM Edition7 UICC	organ dependent<br clear="none"/>

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

UICC/AJCC T category 1.3.6.1.4.1.19376.1.3.11.15

Id

1.3.6.1.4.1.19376.1.3.11.15

Effective Date

valid from 2015‑11‑11 14:05:36

Status

Draft

Version Label

Name

UICC-t-value-7ed

Display Name

UICC T category (7ed)

2 Source Code Systems

2.16.840.1.113883.15.6 - TNM Edition7 UICC

2.16.840.1.113883.5.1008 - Null Flavor

Level/ Type	Code	Display Name	Code System
0‑L	Ta	Ta	TNM Edition7 UICC
0‑L	Tis	Tis	TNM Edition7 UICC
1‑L	Tis(DCIS)	Tis(DCIS)	TNM Edition7 UICC
1‑L	Tis(LCIS)	Tis(LCIS)	TNM Edition7 UICC
1‑L	Tis(Paget)	Tis(Paget)	TNM Edition7 UICC
1‑L	Tis(pu)	Tis(pu)	TNM Edition7 UICC
1‑L	Tis(pd)	Tis(pd)	TNM Edition7 UICC
0‑L	T0	T0	TNM Edition7 UICC
0‑L	T1	T1	TNM Edition7 UICC
1‑L	T1mi	T1mi	TNM Edition7 UICC
1‑L	T1a	T1a	TNM Edition7 UICC
2‑L	T1a1	T1a1	TNM Edition7 UICC
2‑L	T1a2	T1a2	TNM Edition7 UICC
1‑L	T1b	T1b	TNM Edition7 UICC
2‑L	T1b1	T1b1	TNM Edition7 UICC
2‑L	T1b2	T1b2	TNM Edition7 UICC
1‑L	T1c	T1c	TNM Edition7 UICC
1‑L	T1d	T1d	TNM Edition7 UICC
0‑L	T2	T2	TNM Edition7 UICC
1‑L	T2a	T2a	TNM Edition7 UICC
2‑L	T2a1	T2a1	TNM Edition7 UICC
2‑L	T2a2	T2a2	TNM Edition7 UICC
1‑L	T2b	T2b	TNM Edition7 UICC
1‑L	T2c	T2c	TNM Edition7 UICC
1‑L	T2d	T2d	TNM Edition7 UICC
0‑L	T3	T3	TNM Edition7 UICC
1‑L	T3a	T3a	TNM Edition7 UICC
1‑L	T3b	T3b	TNM Edition7 UICC
1‑L	T3c	T3c	TNM Edition7 UICC
1‑L	T3d	T3d	TNM Edition7 UICC
0‑L	T4	T4	TNM Edition7 UICC
1‑L	T4a	T4a	TNM Edition7 UICC
1‑L	T4b	T4b	TNM Edition7 UICC
1‑L	T4c	T4c	TNM Edition7 UICC
1‑L	T4d	T4d	TNM Edition7 UICC
1‑L	T4e	T4e	TNM Edition7 UICC
0‑L	Tx	TX	TNM Edition7 UICC

0‑L	ASKU	Asked, but unknown	Null Flavor

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

UICC/AJCC T category (SCT) 1.3.6.1.4.1.19376.1.3.11.12

Id

1.3.6.1.4.1.19376.1.3.11.12

Effective Date

valid from 2014‑05‑13 15:52:43

Status

Draft

Version Label

Name

UICC-t-value5

Display Name

UICC T category (SCT)

Description

T-Value from UICC classification

Copyright

This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.

2 Source Code Systems

2.16.840.1.113883.6.96 - SNOMED Clinical Terms

2.16.840.1.113883.5.1008 - Null Flavor

Level/ Type	Code	Display Name	Code System
0‑L	261663004	Tumor stage Ta (tumor staging)	SNOMED Clinical Terms
0‑S	44401000	Tis category (finding)	SNOMED Clinical Terms
1‑L	313145008	Tumor stage Tis pu (finding)	SNOMED Clinical Terms
1‑L	313146009	Tumor stage Tis pd (finding)	SNOMED Clinical Terms
0‑L	58790005	T0 category (finding)	SNOMED Clinical Terms
0‑S	23351008	T1 category (finding)	SNOMED Clinical Terms
1‑L	313108002	Tumor stage T1mic (finding)	SNOMED Clinical Terms
1‑L	261646003	Tumor stage T1a (finding)	SNOMED Clinical Terms
2‑L	261647007	Tumor stage T1a1 (finding)	SNOMED Clinical Terms
2‑L	261648002	Tumor stage T1a2 (finding)	SNOMED Clinical Terms
1‑L	261649005	Tumor stage T1b (finding)	SNOMED Clinical Terms
2‑L	313110000	Tumor stage T1b1 (finding)	SNOMED Clinical Terms
2‑L	313111001	Tumor stage T1b2 (finding)	SNOMED Clinical Terms
1‑L	261650005	Tumor stage T1c (finding)	SNOMED Clinical Terms
0‑S	67673008	T2 category (finding)	SNOMED Clinical Terms
1‑L	261651009	Tumor stage T2a (finding)	SNOMED Clinical Terms
1‑L	261652002	Tumor stage T2b (finding)	SNOMED Clinical Terms
1‑L	261653007	Tumor stage T2c (finding)	SNOMED Clinical Terms
0‑S	14410001	T3 category (finding)	SNOMED Clinical Terms
1‑L	261654001	Tumor stage T3a (finding)	SNOMED Clinical Terms
1‑L	261655000	Tumor stage T3b (finding)	SNOMED Clinical Terms
2‑L	261656004	Tumor stage T3bi (finding)	SNOMED Clinical Terms
2‑L	261657008	Tumor stage T3bii (finding)	SNOMED Clinical Terms
1‑L	261658003	Tumor stage T3c (finding)	SNOMED Clinical Terms
0‑S	65565005	T4 category (finding)	SNOMED Clinical Terms
1‑L	261659006	Tumor stage T4a (finding)	SNOMED Clinical Terms
1‑L	261660001	Tumor stage T4b (finding)	SNOMED Clinical Terms
1‑L	261661002	Tumor stage T4c (finding)	SNOMED Clinical Terms
1‑L	261662009	Tumor stage T4d (finding)	SNOMED Clinical Terms
0‑L	67101007	TX category (finding)	SNOMED Clinical Terms

0‑L	ASKU	Asked but unknown	Null Flavor

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

UICC/AJCC N category 1.3.6.1.4.1.19376.1.3.11.16

Id

1.3.6.1.4.1.19376.1.3.11.16

Effective Date

valid from 2015‑11‑11 14:45:19

Status

Draft

Version Label

Name

UICC_n_value

Display Name

UICC N category (7ed)

2 Source Code Systems

2.16.840.1.113883.15.6 - TNM Edition7 UICC

2.16.840.1.113883.5.1008 - Null Flavor

Level/ Type	Code	Display Name	Code System
0‑L	N0	N0	TNM Edition7 UICC
0‑L	N1	N1	TNM Edition7 UICC
1‑L	N1mi	N1mi	TNM Edition7 UICC
1‑L	N1a	N1a	TNM Edition7 UICC
1‑L	N1b	N1b	TNM Edition7 UICC
1‑L	N1c	N1c	TNM Edition7 UICC
0‑L	N2	N2	TNM Edition7 UICC
1‑L	N2mi	N2mi	TNM Edition7 UICC
1‑L	N2a	N2a	TNM Edition7 UICC
1‑L	N2b	N2b	TNM Edition7 UICC
1‑L	N2c	N2c	TNM Edition7 UICC
0‑L	N3	N3	TNM Edition7 UICC
1‑L	N3mi	N3mi	TNM Edition7 UICC
1‑L	N3a	N3a	TNM Edition7 UICC
1‑L	N3b	N3b	TNM Edition7 UICC
1‑L	N3c	N3c	TNM Edition7 UICC
0‑L	NX	Nx	TNM Edition7 UICC

0‑L	ASKU	Asked but unknown	Null Flavor

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

UICC/AJCC N category (SCT) 1.3.6.1.4.1.19376.1.3.11.13

Id

1.3.6.1.4.1.19376.1.3.11.13

Effective Date

valid from 2014‑10‑27 14:47:35

Status

Draft

Version Label

Name

UICC_N_values

Display Name

UICC N category (SCT)

Description

N-Value from UICC classification

Copyright

This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.

2 Source Code Systems

2.16.840.1.113883.6.96 - SNOMED Clinical Terms

2.16.840.1.113883.5.1008 - Null Flavor

Level/ Type	Code	Display Name	Code System
0‑L	62455006	N0 category (finding)	SNOMED Clinical Terms
0‑L	53623008	N1 category (finding)	SNOMED Clinical Terms
1‑L	277672002	Node stage N1a (finding)	SNOMED Clinical Terms
1‑L	277674001	Node stage N1b (finding)	SNOMED Clinical Terms
2‑L	277772008	Node stage N1bi (finding)	SNOMED Clinical Terms
2‑L	277776006	Node stage N1bii (finding)	SNOMED Clinical Terms
2‑L	277777002	Node stage N1biii (finding)	SNOMED Clinical Terms
2‑L	277778007	Node stage N1biv (finding)	SNOMED Clinical Terms
1‑L	369996002	N1c: >7 nodes involved (finding)	SNOMED Clinical Terms
0‑L	46059003	N2 category (finding)	SNOMED Clinical Terms
1‑L	261967001	Node stage N2a (finding)	SNOMED Clinical Terms
1‑L	261968006	Node stage N2b (finding)	SNOMED Clinical Terms
1‑L	261969003	Node stage N2c (finding)	SNOMED Clinical Terms
0‑L	5856006	N3 category (finding)	SNOMED Clinical Terms
1‑L	370012005	N3a: > 6 cm in dimension (finding)	SNOMED Clinical Terms
1‑L	370013000	N3b: extension to supraclavicular fossa (finding)	SNOMED Clinical Terms
0‑L	79420006	NX category (finding)	SNOMED Clinical Terms

0‑L	ASKU	Asked but unknown	Null Flavor

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

UICC/AJCC M category 1.3.6.1.4.1.19376.1.3.11.17

Id

1.3.6.1.4.1.19376.1.3.11.17

Effective Date

valid from 2015‑11‑11 15:53:15

Status

Draft

Version Label

Name

UICC-m-values

Display Name

UICC M category (7ed)

Copyright

This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.

2 Source Code Systems

2.16.840.1.113883.15.6 - TNM Edition7 UICC

2.16.840.1.113883.5.1008 - Null Flavor

Level/ Type	Code	Display Name	Code System
0‑L	M0	M0	TNM Edition7 UICC
0‑L	M1	M1	TNM Edition7 UICC
1‑L	M1mi	M1(mi)	TNM Edition7 UICC
1‑L	M1a	M1a	TNM Edition7 UICC
1‑L	M1b	M1b	TNM Edition7 UICC
1‑L	M1c	M1c	TNM Edition7 UICC
1‑L	M1d	M1d	TNM Edition7 UICC
1‑L	M1e	M1e	TNM Edition7 UICC
1‑L	M1cy	M1(cy)	TNM Edition7 UICC
0‑L	MX	MX	TNM Edition7 UICC

0‑L	ASKU	Asked but unknown	Null Flavor

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

UICC/AJCC M category (SCT) 1.3.6.1.4.1.19376.1.3.11.14

Id

1.3.6.1.4.1.19376.1.3.11.14

Effective Date

valid from 2014‑05‑13 16:11:15

Status

Draft

Version Label

Name

UICC-m-value

Display Name

UICC M category (SCT)

Description

M-Value from UICC classification

Copyright

This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.

2 Source Code Systems

2.16.840.1.113883.6.96 - SNOMED Clinical Terms

2.16.840.1.113883.5.1008 - Null Flavor

Level/ Type	Code	Display Name	Code System
0‑L	30893008	M0 category (finding)	SNOMED Clinical Terms
0‑L	55440008	M1 category (finding)	SNOMED Clinical Terms
1‑L	261927002	Metastasis stage M1a (finding)	SNOMED Clinical Terms
1‑L	261928007	Metastasis stage M1b (finding)	SNOMED Clinical Terms
1‑L	261929004	Metastasis stage M1c (finding)	SNOMED Clinical Terms
0‑L	27167007	MX category (finding)	SNOMED Clinical Terms

0‑L	ASKU	Asked but unknown	Null Flavor

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

UICC/AJCC C-Factor 1.3.6.1.4.1.19376.1.3.11.19

Id

1.3.6.1.4.1.19376.1.3.11.19

Effective Date

valid from 2015‑11‑13 13:56:23

Status

Draft

Version Label

Name

uicc-c-factor-tnm

Display Name

UICC C-Factor

Description

Qualifier for any TNM category coding the certainty of classification by the methods used

Source Code System

2.16.840.1.113883.15.6 - TNM Edition7 UICC

Level/ Type	Code	Display Name	Code System
0‑L	C1	C1	TNM Edition7 UICC
0‑L	C2	C2	TNM Edition7 UICC
0‑L	C3	C3	TNM Edition7 UICC
0‑L	C4	C4	TNM Edition7 UICC
0‑L	C5	C5	TNM Edition7 UICC

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

UICC/AJCC C-Factor (SCT) 1.3.6.1.4.1.19376.1.3.11.20

Id

1.3.6.1.4.1.19376.1.3.11.20

Effective Date

valid from 2015‑06‑22 15:47:55

Status

Draft

Version Label

Name

uicc-c-factor

Display Name

UICC C-Factor (SCT)

Description

Qualifier for any TNM category coding the certainty of classification by the methods used

Copyright

This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.

Source Code System

2.16.840.1.113883.6.96 - SNOMED Clinical Terms

Level/ Type	Code	Display Name	Code System
0‑L	84068000	C1 - TNM certainty factor	SNOMED Clinical Terms
0‑L	76321005	C2 - TNM certainty factor	SNOMED Clinical Terms
0‑L	44756004	C3 - TNM certainty factor	SNOMED Clinical Terms
0‑L	75800005	C4 - TNM certainty factor	SNOMED Clinical Terms
0‑L	59397002	C5 - TNM certainty factor	SNOMED Clinical Terms

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

UICC/AJCC Residual tumor (R) classification 1.3.6.1.4.1.19376.1.3.11.21

Id

1.3.6.1.4.1.19376.1.3.11.21

Effective Date

valid from 2015‑06‑25 11:23:51

Status

Draft

Version Label

Name

UICC-R-status

Display Name

UICC Residual tumor (R) classification

Description

Value set for Residual tumor state with values for extended R-Klassifikation (TNM Suppl. 4th ed.)

Copyright

This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.

5 Source Code Systems

2.16.840.1.113883.6.96 - SNOMED Clinical Terms

2.16.840.1.113883.15.16 - TNM Edition8 UICC

2.16.840.1.113883.15.6 - TNM Edition7 UICC

1.2.276.0.76.3.1.131.1.5.120

2.16.840.1.113883.5.1008 - Null Flavor

Level/ Type	Code	Display Name	Code System	Description
0‑L	258254000	Residual tumor stage R0 (finding)	SNOMED Clinical Terms
1‑L	415675004	Surgical circumferential margin is closest uninvolved margin to malignant neoplasm (finding)	SNOMED Clinical Terms	No residual tumor: R0 > 1mm CRM negative
0‑L	278271003	Residual tumor stage R1 (finding)	SNOMED Clinical Terms
1‑L	384620009	Surgical circumferential margin involved by malignant neoplasm (tumor present 0-1 mm from circumferential resection margin) (finding)	SNOMED Clinical Terms
0‑L	278272005	Residual tumor stage R2 (finding)	SNOMED Clinical Terms
0‑L	258253006	Residual tumor stage RX (finding)	SNOMED Clinical Terms
0‑L	RX	RX	TNM Edition8 UICC
0‑L	R0>1mm	R0 > 1mm	TNM Edition7 UICC
0‑L	R0<1mm	R0 < 1mm	TNM Edition7 UICC
0‑L	R1	R1	TNM Edition8 UICC
1‑L	R1-dir	R1-dir	TNM Edition7 UICC
1‑L	R1(is)	R1(is)	1.2.276.0.76.3.1.131.1.5.120
1‑L	R1(cy)	R1(cy)	1.2.276.0.76.3.1.131.1.5.120
0‑L	R2	R2	TNM Edition8 UICC
1‑L	R2a	R2a	TNM Edition7 UICC
1‑L	R2b	R2b	TNM Edition7 UICC
1‑L	R2c	R2c	TNM Edition7 UICC
0‑L	CRM+	CRM positive	TNM Edition7 UICC
0‑L	CRM-	CRM negative	TNM Edition7 UICC

0‑L	ASKU	Asked but unknown	Null Flavor

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

UICC/AJCC Tumor Serum Markers

Beschreibung

Observation of serum levels of tumor markers coded for germ cell tumors

Value Set Name

Value Set Id

Version / Eingangsdatum

Status

UICCSerumTumorMarkers

2.16.840.1.113883.2.6.60.6.11.21

2015‑11‑08 18:26:39

Entwurf

Ein gültiger Code aus der Codesystem:

Codesystem Name	Codesystem Id	Codesystem Version
TNM Edition7 UICC	2.16.840.1.113883.15.6

Or one of the following:

Quell-Codesystem:

2.16.840.1.113883.15.6 UICC 7. Auflage
2.16.840.1.113883.6.96 SNOMED Clinical Terms

Level/ Typ	Code	Anzeigename	Codesystem	Beschreibung
0-L	S0	S0	UICC 7. Auflage
0-L	S1	S1	UICC 7. Auflage
0-L	S2	S2	UICC 7. Auflage
0-L	S3	S3	SNOMED Clinical Terms
0-L	SX	SX	UICC 7. Auflage

Legende: Typ L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors werden im @nullFlavor Attribut statt in @code angegeben.

Einleitung

Inhaltsverzeichnis

Foreword

Introduction to this Supplement

Open Issues and Questions

Closed Issues

VOLUME 1 - PROFILES

10 Anatomic Pathology Structured Report (APSR) Profile

10.1 APSR Actors/Transactions

10.1.1 Actor Descriptions and Actor Profile Requirements

10.2 APSR Actor Options

10.3 APSR Required Actor Groupings

10.4 APSR Overview

10.4.1 Concepts

10.4.2 Use Cases

10.4.2.1 Use case #1: Single Report

10.4.2.1.1 Single Report Use Case Description

10.4.2.1.2 Single Report Process Flow

10.4.2.1.3 Single Report Example

10.4.2.2 Use Case #2: Multi-step Report

10.4.2.2.1 Multi-step Report Use Case Description

10.4.2.2.2 Multi-step Report Process Flow

10.5 APSR Security Considerations

10.6 APSR Cross Profile Considerations

VOLUME 3 – CONTENT MODULES

1 Introduction

1.1 Overview of the Anatomic Pathology Technical Framework

1.2 Overview of Volume 3

1.3 Audience

1.4 Relationship to Standards

1.5 Relationship to Real World Architecture

1.6 Conventions

1.7 Scope Introduced in the Current Year

1.8 Copyright Permission

1.9 Glossary

2 Content Modules – Basic Principles

3 IHE Transactions

3.1 Cross Enterprise Document Content Transactions

3.1.1 View Option

3.1.2 Document Import Option

3.1.3 Section Import Option

4 IHE Anatomic Pathology Bindings

4.1 Anatomic Pathology Document Binding to XDS, XDM and XDR

4.1.1XDS DocumentEntry Metadata

4.1.1.1XDS DocumentEntry.formatCode

4.1.1.2XDS DocumentEntry.eventCodeList

4.1.1.3XDS DocumentEntry.parentDocumentRelationship

4.1.2XDS SubmissionSet Metadata

4.1.3XDS Folder Metadata

4.1.4 Configuration

5 Namespaces and Vocabularies

5.1 OID tree of PAT TF

5.2 Terminologies and controlled coded vocabularies

5.3 Value Sets

5.4 Namespaces

5.4.1 Namespace protecting extensions to the CDA schema

5.5 References to Content Modules built outside of IHE PAT TF

5.6 IHE Codes for Anatomic Pathology Document Templates

6 Anatomic Pathology Content Modules

6.1 Conventions

6.2 HL7 CDA R2 Content Modules

6.2.1 Organization

6.2.1.1 Various Types of Content Modules

6.2.1.2 General constraints added by IHE PAT to a CDA R2 document

6.2.1.3 Common structure for CDA APSR

6.2.2 Common layout for the specification of a CDA Content Module

6.2.2.1 Content Module Name – OID

6.2.2.1.1 Definition and purpose

6.2.2.1.2 Specification and example

6.2.3 CDA R2 Document Content Modules

6.2.3.1 AP Structured Report (APSR) - 1.3.6.1.4.1.19376.1.8.1.1.1

6.2.3.1.1 Definition and purpose

6.2.3.1.2 Specification and Example

6.2.4 CDA R2 <section> Content Modules

6.2.4.1 Clinical Information <section> - 1.3.6.1.4.1.19376.1.8.1.2.1

6.2.4.1.1 Definition and Purpose

6.2.4.1.2 Specification and Example

6.2.4.2 Intraoperative Observation <section> - 1.3.6.1.4.1.19376.1.8.1.2.2

6.2.4.2.1 Definition and Purpose

6.2.4.2.2 Specification and Example