Einleitung

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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, 2017> 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, each problem organizer as well as each observation may reference any number of specimens using the <specimen> child element. Each of these references may point to a detailed description of the specimen, in the "procedure steps" section.

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 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]), and by the German "Guideline Pathology / Neuropathology" (formerly TM-30) of the Sector Committee Pathology for the implementation of DIN EN ISO/EC 17020.

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 a repeatable “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 structured 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

1 Introduction

The content of this entire section is copied from section 1 of Volume 3 of PaLM TF.

1.1 Overview of the Anatomic Pathology Technical Framework

Integrating the Healthcare Enterprise (IHE) is an international initiative to promote the use of standards to achieve interoperability among health information technology (HIT) systems and effective use of electronic health records (EHRs). IHE provides a forum for care providers, HIT experts and other stakeholders in several clinical and operational domains to reach consensus on standards-based solutions to critical interoperability issues. The primary output of IHE is system implementation guides, called IHE Profiles. IHE publishes each profile through a well-defined process of public review and trial implementation and gathers profiles that have reached final text status into an IHE Technical Framework, of which this volume is a part. For more general information regarding IHE, refer to IHE International website. It is strongly recommended that, prior to reading this volume, the reader familiarizes themselves with the concepts defined in the IHE Technical Frameworks General Introduction.

1.2 Intended Audience

The intended audience of IHE Technical Frameworks Volume 3 is:

• IT departments of healthcare institutions
• Technical staff of vendors participating in the IHE initiative
• Experts involved in standards development

1.3 Overview of Technical Framework Volume 3

Volume 3 is comprised of several distinct sections:

• Section 1 provides background and reference material.
• Section 2 presents the conventions used in this volume to define the content modules.
• Section 3 provides an overview of Content Modules and the terminology used.
• Section 4 is reserved for domain unique Content Module specifications.
• Section 5 lists the namespaces and identifiers defined or referenced and the vocabularies defined or referenced herein.
• Section 6 defines the PaLM domain’s HL7 V3 CDA Content Modules in detail.
• Section 7 defines the PaLM domain’s DICOM content modules in detail.
• Section 8 defines other types of content modules.

The appendices in Volume 3 provide clarification of technical details of the IHE data model and transactions. A glossary of terms and acronyms used in the IHE Technical Framework, including those from relevant standards, is provided in the IHE Technical Frameworks General Introduction. Due to the length of the document, some domains may divide Volume 3 into smaller volumes labeled 3a, 3b, etc. In this case, the Volume 3 appendices are gathered in Volume 3x. Code and message samples may also be stored on the IHE ftp server. In this case, explicit links to the ftp server will be provided in the transaction text.

1.4 Comment Process

IHE International welcomes comments on this document and the IHE initiative. They can be submitted by sending an email to the co-chairs and secretary of the Pathology and Laboratory Medicine domain committees at palm@ihe.net

1.5 Copyright Licenses

IHE International hereby grants to each Member Organization, and to any other user of these documents, an irrevocable, worldwide, perpetual, royalty-free, nontransferable, nonexclusive, non-sublicensable license under its copyrights in any IHE profiles and Technical Framework documents, as well as any additional copyrighted materials that will be owned by IHE International and will be made available for use by Member Organizations, to reproduce and distribute (in any and all print, electronic or other means of reproduction, storage or transmission) such IHE Technical Documents. The licenses covered by this Copyright License are only to those copyrights owned or controlled by IHE International itself. If parts of the Technical Framework are included in products that also include materials owned or controlled by other parties, licenses to use those products are beyond the scope of this IHE document and would have to be obtained from that other party.

1.5.1 Copyright of Base Standards

IHE technical documents refer to and make use of a number of standards developed and published by several standards development organizations. All rights for their respective base standards are reserved by these organizations. This agreement does not supersede any copyright provisions applicable to such base standards. Health Level Seven, Inc. has granted permission to 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.

1.6 Trademark

IHE® and the IHE logo are trademarks of the Healthcare Information Management Systems Society in the United States and trademarks of IHE Europe in the European Community. They may only be used with the written consent of the IHE International Board Operations Committee, which may be given to a Member Organization in broad terms for any use that is consistent with the IHE mission and operating principles.

1.7 Disclaimer Regarding Patent Rights

Attention is called to the possibility that implementation of the specifications in this document may require use of subject matter covered by patent rights. By publication of this document, no position is taken with respect to the existence or validity of any patent rights in connection therewith. IHE International is not responsible for identifying Necessary Patent Claims for which a license may be required, for conducting inquiries into the legal validity or scope of Patents Claims or determining whether any licensing terms or conditions provided in connection with submission of a Letter of Assurance, if any, or in any licensing agreements are reasonable or non-discriminatory. Users of the specifications in this document are expressly advised that determination of the validity of any patent rights, and the risk of infringement of such rights, is entirely their own responsibility. Further information about the IHE International patent disclosure process including links to forms for making disclosures is available here. Please address questions about the patent disclosure process to the secretary of the IHE International Board: secretary@ihe.net

1.8 History of Document Changes

Content Modules for the APSR 2.0 Profile:

• Reconfiguration of the Document content module
• Reconfiguration of the Procedure step section content module
• Introduction of the Additionally Specified Observation section content module
• Reconfiguration of the entry content modules "Problem organizer" and "Specimen procedure steps"
• Introduction of child element content modules "X-specimen identified", "UICC/AJCC-TNM observation", "ICD-O-3 observation", "Assessment scales observation"
• Renewal and completion of value sets.

Transformation of a real-world use case into a valid APSR 2.0 xml instance.

Finishing the Supplement ready to public comment.

2 Conventions

This document has adopted the following conventions for representing the framework concepts and specifying how the standards upon which the IHE Technical Framework is based shall be applied.

2.1 Content Module Modeling and Profiling Conventions

In order to maintain consistent documentation, modeling methods for IHE content modules and profiling conventions for frequently used standards are maintained as an appendix in the IHE Technical Frameworks General Introduction. Methods described include the standards conventions DICOM, HL7 v2.x, HL7 Clinical Document Architecture (CDA) Documents, etc. These conventions are critical to understanding this volume and should be reviewed prior to reading this text.

2.2 Additional Standards Profiling Conventions

This section defines profiling conventions for standards which are not described in the IHE Technical Frameworks General Introduction.
Not Applicable.

3 Content Modules Overview and Terminology

In the future, an appendix to the IHE Technical Frameworks General Introduction will provide an overview of Content Modules. In the interim, information may be available here.
The Pathology and Laboratory Medicine content modules are listed in the table below:
Table 3-1: Pathology and Laboratory Medicine Content Modules

Content Module Acronym	Type of Content Modules	Semantic	Status
XD-LAB	CDA R2 medical document	Clinical Laboratory Structured Report	Final Text
APSR	CDA R2 medical document	Anatomic Pathology Structured Report	Public Comment

4 IHE Pathology and Laboratory Medicine Bindings

4.1 Medical Document Binding to XDS, XDM and XDR

The bindings of the content modules of the PaLM domain leverage the bindings specified by the Patient Care Coordination domain, in PCC TF Volume 2, section 4, with the addition of the constraints specified below.

4.1.1 XDSDocumentEntry Metadata

4.1.1.1 XDSDocumentEntry.eventCodeList

Append this paragraph at the end of the section.

For the APSR content module, The XDSDocumentEntry.eventCodeList 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.

4.1.1.2 XDSDocumentEntry.formatCode

Append this paragraph at the end of the section.

For the APSR content module, The XDSDocumentEntry.formatCode SHALL be urn:ihe:palm:apsr:2016
The associated codingScheme SHALL be 1.3.6.1.4.1.19376.1.2.3

4.1.1.3 XDSDocumentEntry.parentDocumentRelationship

Append this paragraph at the end of the section.

For the APSR content module XDSDocumentEntry.parentDocumentRelationship is constrained to the "RPLC" value. When there is a parent document the current document is a new version of the parent document, replacing it.

• Note 1: A non-final anatomic pathology 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.

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 1.3.6.1.4.1.19376.1.8.1.3 is dedicated to Entry Content Modules.
       Sub-branch 1.3.6.1.4.1.19376.1.8.1.3.6 is the OID of the Problem Organizer
       Sub-branch 1.3.6.1.4.1.19376.1.8.1.4 is dedicated to Element Content Modules	
       Sub-branch 1.3.6.1.4.1.19376.1.8.1.4.9 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, BUT THIS TEMPORARY VOCABULARY IS NO LONGER USED		

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 of AP content built by the PaLM 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

codeSystem	codeSystemName	Description	Owner
2.16.840.1.113883.6.1	LOINC	Logical Observation Identifier Names and Codes	Regenstrief Institute
2.16.840.1.113883.6.8	UCUM	Unified Code for Units of Measure	Regenstrief Institute, and the UCUM Organization
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, used for representing annotation comments in the report	IHE PCC
2.16.840.1.113883.5.4	Act Code	Codesystem for Acts	HL7
2.16.840.1.113883.5.6	ActClass	Codesystem for Act Classes	HL7
2.16.840.1.113883.5.1052	Act Site	Codesystem for Act Sites	HL7
2.16.840.1.113883.5.1065	ProcedureMethod	Codesystem for Procedure Methods	HL7
2.16.840.1.113883.5.111	Role Code	Codesystem for Role Codes	HL7
2.16.840.1.113883.5.129	SpecimenType	Codesystem for Specimen Types	HL7
2.16.840.1.113883.5.84	ObservationMethod	A code system that provides additional detail about the means or technique used to ascertain the observation	HL7
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
1.2.840.10008.2.16.4	DICOM controlled vocabulary	The meanings of codes defined in DICOM, either explicitly or by reference to another part of DICOM or an external reference document or standard [2]	DICOM
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)
2.16.840.1.113883.6.4	ICD-10-PCS	International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)	WHO
1.2.276.0.76.5.464	OPS 2017	Code lists to describe and categorize surgeries and procedures, adapted from WHO ICPM for Germany	DIMDI (WHO)
2.16.840.1.113883.6.174	OMIM	Code lists to describe and categorize human genes. OMIM is a comprehensive, authoritative compendium of human genes and genetic phenotypes that is freely available and updated daily.	OMIM Johns Hopkins University School of Medicine [3]
1.2.276.0.76.3.1.131.1.5.1	DKG Coding Scheme	Internationally agreed-upon code lists to describe and categorize cancer grading systems, adapted for Germany [4]	DKG (Deutsche Krebsgesellschaft)
1.2.276.0.76.5.336	Grading / Differentiation scheme	Code lists to describe and categorize Tumor grading according ICD-O-3, adapted for Germany	HL7.de
1.2.276.0.76.5.401	Localization scheme for distant metastases	Code lists to describe and categorize localization of metastases according UICC, adapted for Germany	HL7.de

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 code and formatCode for Anatomic Pathology Document Template

Merge the content of this section into the current section 5.1.1 of PaLM TF volume 3.

Any AP structured report SHALL be associated with the metadata typeCode = “11526-1”, which is the LOINC code for “Pathology study”.

The table below lists the format codes, template identifiers and media types used by the IHE Profiles specified in the PaLM Technical Framework. Note that the code system for these codes is 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). For more information see XDS Coding System (1.3.6.1.4.1.19376.1.2.3).

Profile	formatCode	Media Type	Template ID
XD-LAB	urn:ihe:lab:xd-lab:2008	text/xml	1.3.6.1.4.1.19376.1.3.3
APSR	urn:ihe:palm:apsr:2016	text/xml	1.3.6.1.4.1.19376.1.8.1.1.1

6 PaLM HL7 CDA Content Modules

6.1 Conventions

• HL7 CDA conventions are defined in the IHE Technical Frameworks General Introduction Appendix E

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

6.2 Folder Modules

Intentionally left blank

6.3 Content Modules

This section defines each IHE Pathology and Laboratory Medicine Content Module in detail, specifying the standards used and the information defined.

6.3.1 CDA Document Content Modules

All persons (including the patient) and organizations mentioned in the CDA Document Content Modules SHALL include the elements name, addr and telecom.

6.3.1.1 Clinical Laboratory Report Content Module

Section unchanged, as in PaLM TF-3

6.3.1.2 Anatomic Pathology Structured Report Content Module

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.
The specification of this Document Content Module is built and published on Art-Decor

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">     <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->   </entry>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->   <component>     <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.1 'IHE Reason for Referral Section' (2016-09-26T07:58:18) -->   </component>  <component>     <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.4 'History of Present Illness Section' (2013-01-31T00:00:00) -->   </component>  <component>     <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.6 'IHE Active Problems Section' (2015-10-05T16:02:07) -->   </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:language​Code 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 @context​Conduction​Ind 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:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 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 @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name 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:represented​Organization 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 @determiner​Code 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 @determiner​Code 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']]]

6.3.1.2.1 General constraints that apply to APSR

• 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.
• 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.

6.3.1.2.2 Common structure for CDA APSR

Figure 6.3.1.2.2-1 summarizes the common structure of the first six 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 6.3.1.2.2-1 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 6.3.1.2.2-2 shows the common structure of the Procedure Step Content Module specified here, too.

Figure 6.3.1.2.2-2 CDA APSR: common structure of machine-readable content for Procedure Step Content Module

6.3.2 Place Holder

Intentionally left blank

6.3.3 Place Holder

Intentionally left blank

6.3.4 CDA R2 <section> Content Modules

6.3.4.1 Clinical Information <section> - 1.3.6.1.4.1.19376.1.8.1.2.1

6.3.4.1.1 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. The only entry for this section is the Problem Organizer Entry module.

6.3.4.1.2 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">     <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->   </entry>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->   <component>     <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.1 'IHE Reason for Referral Section' (2016-09-26T07:58:18) -->   </component>  <component>     <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.4 'History of Present Illness Section' (2013-01-31T00:00:00) -->   </component>  <component>     <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.6 'IHE Active Problems Section' (2015-10-05T16:02:07) -->   </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:language​Code 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 @context​Conduction​Ind 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:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 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 @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name 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:represented​Organization 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 @determiner​Code 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 @determiner​Code 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']]]

6.3.4.2 Intraoperative Observation <section> - 1.3.6.1.4.1.19376.1.8.1.2.2

6.3.4.2.1 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). The only entry for this section is the Problem Organizer Entry module.

6.3.4.2.2 Specification and Example

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/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->   <entry typeCode="COMP" contextConductionInd="true">     <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' Problem Organizer (2015-08-13T10:24:55) -->   </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:language​Code 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:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 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 @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name 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:represented​Organization 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 @determiner​Code 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 @determiner​Code 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 @context​Conduction​Ind bl 0 … 1 F true

6.3.4.3 Macroscopic Observation <section> - 1.3.6.1.4.1.19376.1.8.1.2.3

6.3.4.3.1 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. The only entry for this section is the Problem Organizer Entry module.

6.3.4.3.2 Specification and Example

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	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/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->   <entry typeCode="COMP">     <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->   </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:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 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 @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name 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:represented​Organization 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 @determiner​Code 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 @determiner​Code 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 @context​Conduction​Ind bl 0 … 1 F true

6.3.4.4 Microscopic Observation <section> - 1.3.6.1.4.1.19376.1.8.1.2.4

6.3.4.4.1 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.The only entry for this section is the Problem Organizer Entry module.

6.3.4.4.2 Specification and Example

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	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/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->   <entry>     <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->   </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 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:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 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 @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name 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:represented​Organization 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 @determiner​Code 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 @determiner​Code 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 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 @context​Conduction​Ind bl 0 … 1 F true

6.3.4.5 Additional Specified Observation <section> - 1.3.6.1.4.1.19376.1.3.10.3.1

6.3.4.5.1 Definition and Purpose

The Additional Specified Observation section includes additional pathologic finding(s) and the results of ancillary studies with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken. The only entry for this section is the Problem Organizer Entry module.

6.3.4.5.2 Specification and Example

Id	1.3.6.1.4.1.19376.1.3.10.3.1	Effective Date	valid from 2016‑11‑13 14:28:08
Status	Draft	Version Label	2.0
Name	AdditionalSpecifiedObservationSection	Display Name	Additional Specified Observation Section
Description Template CDA Section (prototype, directly derived from POCD_RM000040 MIF) The Additional Specified Observation section includes additional pathologic finding(s) and the results of ancillary study(yes) with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken.  Further CDA content section modules as subsections are allowed.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.3.1
Label	PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified 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	Adaptation: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example	generated example <section classCode="DOCSECT" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.3.10.3.1"/>  <code code="xxxxx-x" codeSystem="2.16.840.1.113883.6.1" displayName="specified observation"/>  <title>ADDITIONAL SPECIFIED OBSERVATION SECTION</title>  <text/>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016‑06‑21 14:02:11) -->   </author>  <entry typeCode="COMP" contextConductionInd="true">     <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->   </entry></section>
Item DT Card Conf Description Label hl7:section 0 … * R PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation 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 ="xxxxx-x" (specific for the additional specified observation) @codeSystem ="2.16.840.1.113883.6.1"  @displayName ="Pathology report yyyyy (specific) observation"   This section SHALL contain a narrative block, represented by a textelement, 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 MAY contain subsections.  hl7:templateId II 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.10.3.1 hl7:code CE 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section   Constraint The LOINC code SHALL be chosen according the specified observation type @code CONF 1 … 1 F xxxxx-x @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 specified observation hl7:title ST 1 … 1 R Title of the specified observation PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section   CONF element content shall be "ADDITIONAL SPECIFIED OBSERVATION SECTION"   Example MP observation <text>MOLECULAR PATHOLOGY OBSERVATION SECTION</text> hl7:text SD.TEXT 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section 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:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 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 @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name 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:represented​Organization 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 @determiner​Code 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 @determiner​Code 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: 6.3.4.5 Addtional specified 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 @context​Conduction​Ind bl 0 … 1 F true

6.3.4.6 Diagnostic Conclusion <section> - 1.3.6.1.4.1.19376.1.8.1.2.5

6.3.4.6.1 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 sample or group of specimen samples are reported separately. This section may include diagrams and still images or virtual slides, if taken. In case of cancer, this section may also include a the cancer checklist. The only entry for this section is the Problem Organizer Entry module.

6.3.4.6.2 Specification and Example

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/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->   <entry>     <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) 1..* R-->   </entry>  <entry>     <!-- template 1.3.6.1.4.1.19376.1.3.10.4.5 'Update Information Organizer' (2017-11-14T15:22:14) 0..1 R -->   </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 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:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 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 @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name 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:represented​Organization 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 @determiner​Code 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 @determiner​Code 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 … 1 C 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 @context​Conduction​Ind 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 @context​Conduction​Ind bl 0 … 1 F true

6.3.4.7 Procedure steps <section> - 1.3.6.1.4.1.19376.1.8.1.2.6

6.3.4.7.1 Definition and Purpose

The Procedure steps section contains the description of tissue sampling and 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.

6.3.4.7.2 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	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/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->   <entry typeCode="COMP" contextConductionInd="false">     <!-- template 1.3.6.1.4.1.19376.1.3.10.4.1 'Specimen Procedure Step' (2016-07-08T13:20:59) -->   </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:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 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 @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name 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:represented​Organization 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 @determiner​Code 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 @determiner​Code 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 @context​Conduction​Ind bl 0 … 1

6.3.5 CDA R2 <entry> Content Modules

6.3.5.1 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 the Problem Organizer <entry>.

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

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.

6.3.5.2 Problem Organizer – 1.3.6.1.4.1.19376.1.8.1.3.6

6.3.5.2.1 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.

6.3.5.2.2 Specification and Example

Id	1.3.6.1.4.1.19376.1.8.1.3.6	Effective Date	valid from 2015‑08‑13 10:24:55
Status	Draft	Version Label	2.0
Name	ProblemOrganizer	Display Name	Problem Organizer
Description Template CDA Organizer (prototype, directly derived from POCD_RM000040 MIF) The problem organizer groups the battery of observations performed to investigate on a single problem identified on a specimen or group of specimens.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.3.6
Label	PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 7 templates, Uses 11 templates Used by as Name Version 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 1.3.6.1.4.1.19376.1.8.1.1.1 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 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 1.3.6.1.4.1.19376.1.8.1.2.5 Containment Diagnostic Conclusion Section (2.0) 2014‑05‑13 19:31:26 Uses as Name Version 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 1.3.6.1.4.1.19376.1.3.3.1.7 Containment Laboratory Performer (2017) 2008‑08‑08 1.3.6.1.4.1.19376.1.3.10.9.1 Include X Specimen Identified 2014‑12‑22 15:54:30 1.3.6.1.4.1.19376.1.8.1.4.10 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 1.3.6.1.4.1.19376.1.8.1.4.9 Containment AP Observation Entry (2.0) 2014‑05‑14 17:09:54 1.3.6.1.4.1.19376.1.3.1.6 Containment Laboratory Observation (2017) 2008‑08‑08 2.16.840.1.113883.10.12.324 Containment CDA Reference 2005‑09‑07
Relationship	Specialization: template 2.16.840.1.113883.10.12.305 (2005‑09‑07)
Example	generated example <organizer classCode="BATTERY" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.8.1.3.6"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">     <qualifier>       <name code="116677004" codeSystem="2.16.840.1.113883.6.96" displayName=" Associated topography (attribute)"/>      <value nullFlavor="cs" code="all children of "362981000"" codeSystem="2.16.840.1.113883.6.96" displayName="all values from 91723000 (Anatomical structure)"/>    </qualifier>  </code>  <component typeCode="COMP">     <observation>       <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">         <value code="115597007" displayName="Description of specimen character (procedure)" codeSystem="2.16.840.1.113883.6.96"/>      </code>    </observation>  </component>  <statusCode code="completed"/>  <effectiveTime>     <low value="20170131165954"/>  </effectiveTime>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->   </author>  <informant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->   </informant>  <participant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (2016-07-12T18:44:06) -->   </participant>  <performer>     <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->   </performer>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 0..* R -->   <component typeCode="COMP" contextConductionInd="true">     <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (2016-06-22T16:08:01) -->   </component>  <component typeCode="COMP" contextConductionInd="true">     <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' (2005-09-07T00:00:00) -->   </component>  <component typeCode="COMP" contextConductionInd="true">     <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.4.2 'IHE Comment Entry' (2013-12-20T00:00:00) -->   </component>  <component typeCode="COMP" contextConductionInd="true">     <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (2014-05-14T17:09:54) -->   </component>  <component typeCode="COMP" contextConductionInd="true">     <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.3.1.6 'Laboratory Observation' (2008-08-08T00:00:00) -->   </component>  <reference>     <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->   </reference></organizer>
Example	example for use case #1, problem: invasive breast cancer <organizer classCode="BATTERY" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.8.1.3.6"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_Problem1"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>  <statusCode code="completed"/>  <effectiveTime>     <low value="201001041605-0500"/>  </effectiveTime>  <!--The problem is expressed by the result of the observation having the same code as organizer/code-->   <component>     <observation classCode="OBS" moodCode="EVN">       <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>      <value code="C50.9" codeSystem="2.16.840.1.113883.6.3" displayName="Malignant neoplasm of breast, unspecified" codeSystemDisplayName="ICD-10"/>    </observation>  </component>  <component typeCode="COMP" contextConductionInd="true">     <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (2014-05-14T17:09:54) -->   </component>  <reference>     <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->   </reference></organizer>
Item DT Card Conf Description Label hl7:organizer 0 … * R Problem organizer groups the battery of observations performed to investigate on a single problem identified on a specimen or a group of specimens.  PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer @classCode cs 1 … 1 F BATTERY @moodCode cs 1 … 1 F EVN hl7:templateId II 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.3.6 hl7:id II 0 … * R PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer hl7:code CD (required) 0 … 1 R Problem PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer @code CONF 0 … 1 F 75326-9 @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 Problem hl7:component 0 … 1 R Coding of the Problem reported PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer @typeCode cs 1 … 1 F COMP hl7:observation 0 … 1 R PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer hl7:code CD (extensible) 1 … 1 R PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer @code CONF 0 … 1 F 75326-9 @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 Problem hl7:qualifier CR 0 … * R Optional qualifier for separate problems with identical problem type in one specimen, e.g. a urothelial bladder cancer Invasive cancer) and a prostate cancer (invasive cancer) in one cystoprostatectomy specimen. The anatomic structure is able to differentiate. PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer   Example Problem in urinary bladder in cystoprostatectomy specimen <qualifier>   <name code="116677004" codeSystem="2.16.840.1.113883.6.96" displayName="Associated topography (attribute)" codeSystemName="SNOMED-CT"/>  <value code="302512001" codeSystem="2.16.840.1.113883.6.96" displayName=" Entire urinary bladder (body structure)" codeSystemName="SNOMED-CT"/></qualifier> hl7:name CV 0 … 1 R PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer @code cs 1 … 1 F 116677004 @codeSystem oid 1 … 1 F 2.16.840.1.113883.6.96 @displayName st 1 … 1 F Associated topography (attribute) hl7:value CD (extensible) 0 … * R PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer @code CONF 0 … 1 F << 91723000 @codeSystem 0 … 1 F 2.16.840.1.113883.6.96 (SNOMED Clinical Terms) @codeSystemName 0 … 1 F SNOMED-CT @displayName 0 … 1 F all values from Anatomical structure hl7:value CE (extensible) 0 … 1 R Code of the problem reported PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer   CONF @code shall be "any_code" @codeSystem shall be "2.16.840.1.113883.6.3" @codeSystemName shall be "any_code" @displayName shall be "ICD-10" or The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.7 Problem Type (2016‑07‑11 09:52:19) hl7:statusCode CS (required) 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer   Constraint The status of the organizer is  completed  if the battery of observations for this problem has been performed. It is  aborted  in case some of the intended observations could not be achieve and have been aborted, and appear as such below the organizer.   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 Organizer time. The period of time (possibly reduced to a point in time) during which the information was collected and assembled.  PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer hl7:author 0 … * C Author Source: PaLM 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. 2.0‑3: 6.3.5.2 Problem organizer where [hl7:author [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.2']]]   Constraint The author SHALL be present if it is different from the main author of the report. For instance the author could be the ordering physician contributing to the Clinical Information section, inside a report authored by the pathologist. hl7:informant 0 … * R Informant The informant is an actor (person and organization) who provided some of the clinical information carried by this organizer. 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. 2.0‑3: 6.3.5.2 Problem organizer where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.6']] hl7:participant 0 … * R Transcriptionist, Device, Responsible, Validator Source: PaLM 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. 2.0‑3: 6.3.5.2 Problem organizer where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.7']]   Constraint participationType "ENT", "DEV", "RESP", "AUTHEN" hl7:performer 0 … 1 C Performing lab. The performing laboratory is present at this level only if this particular problem on this particular specimen was investigated by a (subcontractor) distinct laboratory from the one issuing the consolidated report 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. 2.0‑3: 6.3.5.2 Problem organizer where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']] 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) Specimen identification outside an AP observation for differentiating or restituting the problem type Source: PaLM Suppl. APSR 2.0-3: 6.3.6.9 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:component 0 … * R Embedded image This organizer may carry an image focusing on the problem, either directly embedded or encapsulated within a region of interest. Contains 1.3.6.1.4.1.19376.1.8.1.4.10 Embedded Image IHE (2016‑06‑22 16:08:01) PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer where [hl7:observationMedia [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.10']]] @typeCode cs 0 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true   Constraint [@classCode="ROIOVL" and moodCode="EVN"] hl7:sequenceNumber INT 0 … 1 PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer hl7:seperatableInd BL 0 … 1 PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer hl7:component 0 … * R Region of interest This organizer may carry an image focusing on the problem, either directly embedded or encapsulated within a region of interest. In the latter case by an entryRelationship @typeCode="SUBJ" Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (2005‑09‑07) PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer where [@typeCode='COMP'] [hl7:regionOfInterest [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.307']]] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true   Constraint [@classCode="ROIOVL" and moodCode="EVN"] hl7:sequenceNumber INT 0 … 1 PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer hl7:seperatableInd BL 0 … 1 PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer hl7:component 0 … * R General comment on this particular problem  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 Suppl. 2.0‑3: 6.3.5.2 Problem organizer where [@typeCode='COMP'] [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 COMP @context​Conduction​Ind bl 0 … 1 F true hl7:sequenceNumber INT 0 … 1 PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer hl7:seperatableInd BL 0 … 1 PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer hl7:component 0 … * R Any kind of AP observation, for complex observations, e.g. for TNM, ICD-O-3, or Assessment scales, the appropriate templates may be used. Source: PaLM 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 Suppl. 2.0‑3: 6.3.5.2 Problem organizer 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 @context​Conduction​Ind bl 0 … 1 F true hl7:sequenceNumber INT 0 … 1 PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer hl7:seperatableInd BL 0 … 1 PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer hl7:component 0 … * C Laboratory observation Contains 1.3.6.1.4.1.19376.1.3.1.6 Laboratory Observation (2008‑08‑08) PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer where [@typeCode='COMP'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.1.6']]] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true hl7:sequenceNumber INT 0 … 1 PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer hl7:seperatableInd BL 0 … 1 PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer hl7:reference 0 … * R Reference to an external document, or to external organizers, 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 Suppl. 2.0‑3: 6.3.5.2 Problem organizer

6.3.5.3 Specimen Procedure Step <entry> - 1.3.6.1.4.1.19376.1.3.10.4.1

6.3.5.3.1 Definition and purpose

The Specimen Procedure Step <entry> Content Module contains in machine-readable form all the data concerning one specimen or a group of specimens together with its container(s). 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, 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.
The resulting specimen is the participant in the procedure according to the CDA-RIM (fig. 6.2.5.3.2-1) with the typeCode="PRD", and the role of "SPEC". The specimen ID is the ParticipantRole.ID.
Additives (e.g. fixatives) MAY be additional participants with the typeCode="CSM".
Each specimen is put in or on an appropriate container. The container is described through an EntryRelationship to a Supply whose product is the container (see this volume, 6.3.6.4).
The specimen reception in laboratory may be expressed through another EntryRelationship of typeCode "COMP", introducing the "specimen received" Act.
In case the procedure step produces a child specimen, the parent specimen is the specimen on which the procedure is performed. Thus the parent specimen is represented by a Specimen participation to the procedure. In this case, Specimen.SpecimenRole.Id is the id of the parent specimen. These parent specimens might be multiple, for instance in the case of TMA.Therefore, cardinalities of Specimen are [0..*]
Specimen and their containers carry IDs as well as further attributes, which are defined in the HL7 Specimen DAM.

HL7 DAM Specimen Release 1.

Figure 6.3.5.3.1-1 CDA-RMIM of the Specimen Procedure Steps <entry>

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, 1.3.6.1.4.1.19376.1.3.10.9.21). The

The Code systems and Value sets MAY be organized organ-specific.

6.3.5.3.2 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 <procedure negationInd="false" classCode="PROC" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.3.10.4.1"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="117617002" displayName="Immunohistochemistry procedure (procedure)" codeSystem="2.16.840.1.113883.5.96">     <qualifier>       <name code="246094008 or 246355002" codeSystem="2.16.840.1.113883.6.96" displayName="Component investigated (attribute) or Supporting structure (attribute)"/>      <value code="23307004" codeSystem="2.16.840.1.113883.6.96" displayName="Estrogen receptor (substance)"/>    </qualifier>  </code>  <text/>  <statusCode code="completed"/>  <effectiveTime>     <low value="20161110104817"/>  </effectiveTime>  <targetSiteCode code="441652008" codeSystem="2.16.840.1.113883.6.96" displayName="Formalin-fixed paraffin-embedded tissue specimen (specimen)"/>  <specimen typeCode="SPC">     <specimenRole classCode="SPEC">       <id/>    </specimenRole>  </specimen>  <performer>     <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->   </performer>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->   </author>  <participant>     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.44 'CDA Participant (Body) Procedure Steps APSR2' (2014-10-26T17:06:28) -->   </participant>  <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">     <seperatableInd value="false"/>    <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.22 'CDA Supply Container APSR2' (2016-07-29T12:09:33) -->   </entryRelationship>  <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">     <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.3.1.3 'Specimen Received' (2008-08-08T00:00:00) -->   </entryRelationship>  <entryRelationship negationInd="false" typeCode="REFR" inversionInd="false" contextConductionInd="true">     <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.4.1 'Specimen Procedure Step' (2016-07-08T13:20:59) -->   </entryRelationship>  <reference>     <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->   </reference></procedure>
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:target​Site​Code 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">     <!-- Parent specimen ID -->     <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 @context​Conduction​Ind 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 @context​Conduction​Ind 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 @context​Conduction​Ind 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

6.3.6 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.

6.3.6.1 Specimen Collector in Header – 1.3.6.1.4.1.19376.1.8.1.4.1

6.3.6.1.1 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)

6.3.6.1.2 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 <participant typeCode="DIST" contextControlCode="OP">   <templateID root="1.3.6.1.4.1.19376.1.8.1.4.1"/>  <time>     <low value="20170127121035"/>  </time>  <associatedEntity classCode="PROV">     <id root="1.2.3.999" extension="--example only--"/>    <code code="--code--" codeSystem="2.16.840.1.113883.5.111"/>    <addr>addr</addr>    <telecom/>    <associatedPerson>       <!-- template 2.16.840.1.113883.10.12.152 'CDA Person' (dynamic) -->     </associatedPerson>    <scopingOrganization>       <!-- template 2.16.840.1.113883.10.12.151 'CDA Organization' (dynamic) -->     </scopingOrganization>  </associatedEntity></participant>
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:associated​Entity 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:associated​Person 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:scoping​Organization 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

6.3.6.2 Author – 1.3.6.1.4.1.19376.1.8.1.4.2

6.3.6.2.1 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.

6.3.6.2.2 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:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 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 @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name 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:represented​Organization 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 @determiner​Code 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 @determiner​Code 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

6.3.6.3 Content Validator – 1.3.6.1.4.1.19376.1.8.1.4.3

6.3.6.3.1 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.

6.3.6.3.2 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:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 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 @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name 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:represented​Organization 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 @determiner​Code 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 @determiner​Code 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

6.3.6.4 Specimen Container in Specimen Procedure Step - 1.3.6.1.4.1.19376.1.3.10.9.22

6.3.6.4.1 Definition and purpose

This Supporting Content Module is usable in the Specimen Procedure Steps <entry> (see 6.2.6.4). 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

6.3.6.4.2 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 <supply classCode="SPLY" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.3.10.9.22"/>  <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_block_A_1-C"/>  <code code="74384-9" codeSystem="2.16.840.1.113883.6.1" displayName="Specimen container"/>  <text/>  <statusCode code="completed"/>  <effectiveTime/>  <priorityCode/>  <repeatNumber/>  <independentInd value="false"/>  <quantity value="1"/>  <expectedUseTime>     <low value="201001030905-0500"/>  </expectedUseTime>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 0..* O ID of the specimen linked to the container -->   <specimen typeCode="SPC">     <specimenRole classCode="SPEC">       <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_block_A_1"/>    </specimenRole>  </specimen>  <product typeCode="PRD">     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.24 'CDA ManufacturedProduct APSR2' (2016-09-09T12:37:49) -->   </product>  <performer>     <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->   </performer>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->   </author>  <informant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->   </informant>  <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">     <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 2.16.840.1.113883.10.12.300 'CDA Clinical Statement' (2005-09-07T00:00:00) -->   </entryRelationship></supply>
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 @context​Conduction​Ind 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

6.3.6.5 Informant – 1.3.6.1.4.1.19376.1.8.1.4.6

6.3.6.5.1 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.

6.3.6.5.2 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	Example <!-- choice: 1..1 element hl7:assignedEntity containing template 2.16.840.1.113883.10.12.153 (dynamic) element hl7:relatedEntity containing template 2.16.840.1.113883.10.12.316 (dynamic) -->
Item DT Card Conf Description Label @typeCode cs 0 … 1 F INF @context​Control​Code 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

6.3.6.6 Additional participant in an entry - 1.3.6.1.4.1.19376.1.8.1.4.7

6.3.6.6.1 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.

6.3.6.6.2 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"/>  <!-- choice: 0..1 element hl7:playingDevice containing template 2.16.840.1.113883.10.12.315 (dynamic) element hl7:playingEntity containing template 2.16.840.1.113883.10.12.313 (dynamic) --> </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) @context​Control​Code 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

6.3.6.7 Anatomic Pathology Observation template – 1.3.6.1.4.1.19376.1.8.1.4.9

6.3.6.7.1 Definition and purpose

This Content Module is usable within a Problem Organizer.

The “AP Observation” generic template is usable for all AP observations, including those on findings from 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. For measurement results the UCUM system should be used.

6.3.6.7.2 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 <observation classCode="OBS" moodCode="EVN" negationInd="false">   <templateId root="1.3.6.1.4.1.19376.1.8.1.4.9"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="16112-5" codeSystem="2.16.840.1.113883.6.1" displayName="Estrogen receptor [Interpretation] in Tissue"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>     <low value="20161129162112"/>  </effectiveTime>  <value xsi:type="CD" code="416053008" displayName="Estrogen receptor positive tumor (disorder)" codeSystem="2.16.840.1.113883.6.96"/>  <methodCode code="0107" displayName="Microscopy" codeSystem="2.16.840.1.113883.5.84"/>  <performer>     <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'CDA Performer IHE (Body)' (dynamic) -->   </performer>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) -->   </author>  <informant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Body) APSR2' (dynamic) -->   </informant>  <participant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (dynamic) -->   </participant>  <entryRelationship xsi:type="" typeCode="COMP">     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (dynamic) -->   </entryRelationship>  <entryRelationship xsi:type="" typeCode="COMP">     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (dynamic) -->   </entryRelationship>  <entryRelationship xsi:type="" typeCode="COMP">     <!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' (dynamic) -->   </entryRelationship>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 0..* O -->   <reference>     <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (dynamic) -->   </reference></observation>
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>   <!-- which specimen is used for this observation -->   <specimenRole>     <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="slide_A_1_PR"/>  </specimenRole></specimen> 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

6.3.6.8 Embedded Image – 1.3.6.1.4.1.19376.1.8.1.4.10

6.3.6.8.1 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.

6.3.6.8.2 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 <observationMedia classCode="OBS" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.8.1.4.10"/>  <id root="1.2.3.999" extension="--example only--"/>  <languageCode code="en"/>  <value mediaType="application" representation="B64"/>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 1..1 M -->   <performer>     <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->   </performer>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->   </author>  <informant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->   </informant>  <entryRelationship negationInd="false" typeCode="SUBJ" inversionInd="true" contextConductionInd="true">     <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.4.2 'IHE Comment Entry' (2013-12-20T00:00:00) -->   </entryRelationship></observationMedia>
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

6.3.6.9 X Specimen Identified - 1.3.6.1.4.1.19376.1.3.10.9.1

6.3.6.9.1 Definition and purpose

This Specimen Identification <entry> provides the machine-readable links between any type of procedure or observation or embedded image or containers to the specimen, on that this procedure is performed (parent specimen), or 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 Problem Organizer, Specimen Procedure Steps, Observations, Embedded images, and Containers in Specimen Procedure Steps.

6.3.6.9.2 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	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

6.3.6.10 UICC/AJCC TNM Staging and Grading - 1.3.6.1.4.1.19376.1.3.10.4.2

6.3.6.10.1 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. A series of supporting templates is used for all the detailed descriptions of the elements of the TNM system.

Figure 6.3.6.10.1-1 CDA-RMIM of the UICC/AJCC TNM <entry>

6.3.6.10.2 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 <observation classCode="OBS" moodCode="ENV" negationInd="false">   <templateId root="1.3.6.1.4.1.19376.1.3.10.4.2"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="21902-2" codeSystem="2.16.840.1.113883.6.1"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>     <low value="20170712152253"/>  </effectiveTime>  <value xsi:type="CD" code="IIA" displayName="stage IIA" codeSystem="2.16.840.1.113883.15.6"/>  <performer>     <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->   </performer>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->   </author>  <informant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->   </informant>  <participant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (2016-07-12T18:44:06) -->   </participant>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 1..* M -->   <entryRelationship>     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.32 'TNM y' (2015-06-22T17:28:17) -->   </entryRelationship>  <entryRelationship>     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.30 'TNM a ' (2015-06-22T15:13:46) -->   </entryRelationship>  <entryRelationship>     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.31 'TNM r' (2015-06-22T17:38:42) -->   </entryRelationship>  <entryRelationship>     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.25 'TNM T-Observation' (2014-12-02T15:54:17) -->   </entryRelationship>  <entryRelationship>     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.26 'TNM N-Observation' (2014-12-02T16:34:50) -->   </entryRelationship>  <entryRelationship>     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.27 'TNM M-Observation' (2014-12-02T16:32:30) -->   </entryRelationship>  <entryRelationship>     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.33 'TNM Serum tumor markers' (2015-11-06T14:28:44) -->   </entryRelationship>  <entryRelationship>     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.34 'TNM Lymphatic Invasion' (2015-11-16T14:01:58) -->   </entryRelationship>  <entryRelationship>     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.35 'TNM Venous Invasion' (2015-11-16T13:40:28) -->   </entryRelationship>  <entryRelationship>     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.36 'TNM Perineural Invasion' (2015-11-11T16:13:40) -->   </entryRelationship>  <entryRelationship>     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.28 'TNM Grading' (2015-11-15T13:01:18) -->   </entryRelationship>  <entryRelationship>     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.29 'TNM R-status' (2015-06-30T13:38:30) -->   </entryRelationship></observation>
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

6.3.6.11 ICD-O-3 Typing and Grading - 1.3.6.1.4.1.19376.1.3.10.4.3

6.3.6.11.1 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 typing and grading of a tumor or a systemic malignancy according the WHO regulations for the ICD-O-3 system. A series of supporting templates is used for all the detailed descriptions of the elements of the ICD-O-3 system.

Figure 6.3.6.11.1-1 CDA-RMIM of the ICD-O-3 <entry>

6.3.6.11.2 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 <observation classCode="OBS" moodCode="EVN" negationInd="false">   <templateId root="1.3.6.1.4.1.19376.1.3.10.4.3"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_ICDO"/>  <code code="31205-8" codeSystem="2.16.840.1.113883.6.1" displayName="Histology ICD-O-3 Cancer"/>  <statusCode code="completed"/>  <effectiveTime>     <low value="201001041405-0500"/>  </effectiveTime>  <value xsi:type="CD" code="8500/3" codeSystem="2.16.840.1.113883.6.43.1"/>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->   </author>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 1..* R -->   <specimen typeCode="SPC">     <specimenRole classCode="SPEC">       <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_slide_A1_HE"/>    </specimenRole>  </specimen>  <entryRelationship typeCode="SPRT">     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.38 'ICD-O-3 Behavior' (2015-12-03T09:11:54), not used in use case #1 -->   </entryRelationship>  <entryRelationship typeCode="SPRT">     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.39 'ICD-O-3 Differentiation' (2015-12-09T17:12:30) -->   </entryRelationship>  <entryRelationship typeCode="COMP">     <!-- template 1.3.6.1.4.1.19376.1.3.10.4.4 'Assessment Scales Observation for Scoring Systems APSR2' (2016-10-06T13:12:00) -->   </entryRelationship>  <reference>     <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->   </reference></observation>
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

6.3.6.12 Assessment Scales for Scoring systems - 1.3.6.1.4.1.19376.1.3.10.4.4

6.3.6.12.1 Definition and purpose

The Assessment Scales <entry> Content Modul contains in machine-readable form all the information concerning (semi)quantitative 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 6.3.6.12.1-1 CDA-RMIM of an Assessment Scales <entry>

6.3.6.12.2 Specification and Example

Id	1.3.6.1.4.1.19376.1.3.10.4.4	Effective Date	valid from 2016‑10‑06 13:12:00 There are versions of templates with this id: AssessmentScalesObservationScoringSystemsAPSR as of 2016‑10‑06 13:12:00 AssessmentScalesScoringSystemsAPSR as of 2016‑10‑06 12:36:29 CDASupplyContainerAPSR2 as of 2016‑07‑29
Status	Draft	Version Label	2.0
Name	AssessmentScalesObservationScoringSystemsAPSR	Display Name	Assessment Scales Observation for Scoring Systems APSR2
Description Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF) Assessment scale observation for Scoring Systems, e.g. Nottingham- (Elston-Ellis-) Grading for invasive breast cancers, describing the summarized scale value
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.4
Label	PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Classification	CDA Entry Level Template
Open/Closed	Closed (only defined elements are allowed)
Used by / Uses	Used by 0 transactions and 1 template, Uses 7 templates Used by as Name Version 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 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 1.3.6.1.4.1.19376.1.3.10.9.42 Containment Assessment Scoring System APSR 2.0 (2.0) 2016‑10‑10 11:33:36 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, ER-Allred Score <observation classCode="OBS" moodCode="EVN" negationInd="false">   <templateId root="1.3.6.1.4.1.19376.1.3.10.4.4"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="273249006" codeSystem="2.16.840.1.113883.6.96" displayName="Assessment scales"/>  <derivationExpr text="sum"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>     <low value="20170711113628"/>  </effectiveTime>  <priorityCode code="R" displayName="routine" codeSystem="2.16.840.1.113883.5.7"/>  <repeatNumber/>  <value xsi:type="PQ" value="8"/>  <interpretationCode code="RR" displayName="Reactive" codeSystem="2.16.840.1.113883.5.83"/>  <methodCode code="0114" codeSystem="2.16.840.1.113883.1.11.14079" displayName="Microscopy, Light"/>  <performer>     <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->   </performer>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->   </author>  <informant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->   </informant>  <participant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (2016-07-12T18:44:06) -->   </participant>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 0..* R -->   <entryRelationship typeCode="SPRT">     <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.42 'Assessment Scoring System APSR 2.0' (2016-10-10T11:33:36) -->   </entryRelationship>  <reference>     <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->   </reference>  <referenceRange typeCode="REFV">     <observationRange classCode="OBS" moodCode="EVN.CRT">       <code code="--code--" codeSystem="2.16.840.1.113883.5.4"/>      <text/>      <value xsi:type="ANY"/>      <interpretationCode code="CAR" displayName="Carrier" codeSystem="2.16.840.1.113883.5.83"/>    </observationRange>  </referenceRange></observation>
Item DT Card Conf Description Label hl7:observation 0 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales @classCode cs 0 … 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: 6.3.6.12 Assessment scales @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.10.4.4 hl7:id II 0 … * R PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales hl7:code CE (extensible) 1 … 1 M Assessment scale, e.g. grading by scoring PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales   CONF @code shall be "273249006" @codeSystem shall be "2.16.840.1.113883.6.96" @codeSystemName shall be "SCT" @displayName shall be "Assessment scales" or The value of @code should be drawn from value set 2.16.840.1.113883.1.11.19918 ActCoverageAssessmentObservationValue (2014‑03‑26)   Example for use case #1 <code code="273249006" codeSystem="2.16.840.1.113883.6.96" displayName="Assessment scales (assessment scale)"/> hl7:derivationExpr ST 0 … 1 R This optional field can be used to specify how the total score is calculated. In most cases the total score will be the sum of its components. But complex mathematical functions and/or logical operations are possible as well. PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales hl7:text ED 0 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales   Example for use case #1 <text>Nottingham combined grad I (1 of 3)</text> hl7:statusCode CS 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales   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 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: 6.3.6.12 Assessment scales hl7:value ANY 1 … * R any total value of a scoring systems, e.g. Gleason score, van Nuys score, etc., either with data type INT or with data type CD or CO  PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales   Example for use case #1, Nottingham combined grade I <value value="1"/> hl7:interpretationCode CE 0 … * R PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26) hl7:methodCode CE 0 … * R PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales @code CONF 0 … 1 F 0114 @codeSystem 0 … 1 F 2.16.840.1.113883.1.11.14079 @codeSystemName 0 … 1 F HL7 @displayName 0 … 1 F Microscopy, Light 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: 6.3.6.12 Assessment scales 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: 6.3.6.12 Assessment scales 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: 6.3.6.12 Assessment scales 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: 6.3.6.12 Assessment scales where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.7']] 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:entryRelationship 0 … * R Contains 1.3.6.1.4.1.19376.1.3.10.9.42 Assessment Scoring System APSR 2.0 (2016‑10‑10 11:33:36) PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.42']]] @typeCode cs 1 … 1 F SPRT hl7:sequenceNumber INT 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales hl7:reference 0 … * R Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07) PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales hl7:referenceRange 0 … * R PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales @typeCode cs 1 … 1 F REFV hl7:observationRange 1 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales @classCode cs 0 … 1 F OBS @moodCode cs 0 … 1 F EVN.CRT hl7:code CD 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.4 (Act Code) hl7:text ED 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales hl7:value ANY 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales hl7:interpretationCode CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)

VOLUME 4 - VALUE SETS

4 APSR Value Sets

4.1 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

4.2 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.

4.3 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.

4.4 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.

4.5 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 Designations 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
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4.6 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"/>
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4.7 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
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4.8 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
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4.9 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.

4.10 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.

4.11 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.

4.12 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.

4.13 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.

4.14 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.

4.15 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.

4.16 UICC/AJCC clinical/pathological 1.3.6.1.4.1.19376.1.3.11.22

Id	1.3.6.1.4.1.19376.1.3.11.22	Effective Date	valid from 2015‑11‑04 15:52:34
Status	Draft	Version Label
Name	UICC-clinical-pathological	Display Name	UICC clinical/pathological
Description	Qualifiers for each TNM category classifying the observation method and the time frame of observation in relation to treatment
3 Source Code Systems	2.16.840.1.113883.15.16 - TNM Edition8 UICC 1.2.276.0.76.11.9 - hl7de-valueset-9 2.16.840.1.113883.5.1008 - Null Flavor
Level/ Type Code Display Name Code System Description 0‑L p p TNM Edition8 UICC The pathological assessment of the primary tumor entails a resection of the primary tumor or a biopsy adequate to evaluate the highest T category. The pathological assessment of the regional lymph nodes entails a removal of lymph nodes adequate to validate the absence of regional lymph node metastasis or sufficient to evaluate the highest pN category. The pathological assessment of distant metastasis entails microscopic examination. 0‑L c c TNM Edition8 UICC The clinical classification is based on evidence acquired before treatment 1‑L u u hl7de-valueset-9 The clinical classification is based on ultrasound evidence acquired before treatment 1‑L ct ct hl7de-valueset-9 The clinical classification is based on CT imaging evidence acquired before treatment 1‑L mr mr hl7de-valueset-9 The clinical classification is based on magnetic resonance imaging evidence acquired before treatment 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.

4.17 UICC/AJCC Venous Invasion 1.3.6.1.4.1.19376.1.3.11.23

Id	1.3.6.1.4.1.19376.1.3.11.23	Effective Date	valid from 2015‑11‑04 16:17:55
Status	Draft	Version Label
Name	UICC-vene-invasion	Display Name	UICC Venous Invasion
Description	Observation for tumor spread coding the degree of venous invasion
2 Source Code Systems	2.16.840.1.113883.15.16 - TNM Edition8 UICC 2.16.840.1.113883.5.1008 - Null Flavor
Level/ Type Code Display Name Code System 0‑L V0 V0 TNM Edition8 UICC 0‑L V1 V1 TNM Edition8 UICC 0‑L V2 V2 TNM Edition8 UICC 0‑L VX VX TNM Edition8 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.

4.18 UICC/AJCC Lymphatic Invasion 1.3.6.1.4.1.19376.1.3.11.24

Id	1.3.6.1.4.1.19376.1.3.11.24	Effective Date	valid from 2015‑11‑04 16:19:20
Status	Draft	Version Label
Name	UICC-lymphatic-invasion	Display Name	UICC Lymphatic Invasion
Description	Observation for tumor spread coding the degree of lymphatic invasion
2 Source Code Systems	2.16.840.1.113883.15.16 - TNM Edition8 UICC 2.16.840.1.113883.5.1008 - Null Flavor
Level/ Type Code Display Name Code System 0‑L L0 L0 TNM Edition8 UICC 0‑L L1 L1 TNM Edition8 UICC 0‑L LX LX TNM Edition8 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.

4.19 UICC/AJCC Perineurial Invasion 1.3.6.1.4.1.19376.1.3.11.25

Id	1.3.6.1.4.1.19376.1.3.11.25	Effective Date	valid from 2015‑11‑04 16:20:42
Status	Draft	Version Label
Name	UICC-perineural-invasion	Display Name	UICC Perineural Invasion
Description	Observation for tumor spread coding the degree of perineural (lymphatic nerve sheet) invasion
2 Source Code Systems	2.16.840.1.113883.15.16 - TNM Edition8 UICC 2.16.840.1.113883.5.1008 - Null Flavor
Level/ Type Code Display Name Code System Description 0‑L Pn0 Pn0 TNM Edition8 UICC no perineural invasion 0‑L Pn1 Pn1 TNM Edition8 UICC Perineural invasion 0‑L PnX PnX TNM Edition8 UICC unknown 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.

4.20 UICC/AJCC Mucosa 1.3.6.1.4.1.19376.1.3.11.26

Id	1.3.6.1.4.1.19376.1.3.11.26	Effective Date	valid from 2015‑11‑04 16:22:04
Status	Draft	Version Label
Name	UICC-mucosa	Display Name	UICC Mucosa
Source Code System	1.2.276.0.76.3.1.131.1.5.1
Level/ Type Code Display Name Code System Description 0‑L m1 m1 1.2.276.0.76.3.1.131.1.5.1 restricted to mucosa, 1st third 0‑L m2 m2 1.2.276.0.76.3.1.131.1.5.1 restricted to mucosa, 2nd third 0‑L m3 m3 1.2.276.0.76.3.1.131.1.5.1 restricted to mucosa, 3rd third
Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

4.21 UICC/AJCC Submucosa 1.3.6.1.4.1.19376.1.3.11.27

Id	1.3.6.1.4.1.19376.1.3.11.27	Effective Date	valid from 2015‑11‑04 16:23:24
Status	Draft	Version Label
Name	UICC-submucosa	Display Name	UICC Submucosa
Source Code System	1.2.276.0.76.3.1.131.1.5.1
Level/ Type Code Display Name Code System Description 0‑L sm1 sm1 1.2.276.0.76.3.1.131.1.5.1 restricted to submucosa, 1st third 0‑L sm2 sm2 1.2.276.0.76.3.1.131.1.5.1 restricted to submucosa, 2nd third 0‑L sm3 sm3 1.2.276.0.76.3.1.131.1.5.1 restricted to submucosa, 3rd third
Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

4.22 UICC/AJCC Localization of distant metastases 1.3.6.1.4.1.19376.1.3.11.28

Id	1.3.6.1.4.1.19376.1.3.11.28	Effective Date	valid from 2015‑11‑04 16:26:53
Status	Draft	Version Label
Name	UICC-distant-metastasis-localization	Display Name	UICC Localization of distant metastases
Description	Qualifier for M category coding the localization of distant metastasis in case of M1 or M2
Source Code System	2.16.840.1.113883.15.16 - TNM Edition8 UICC
Level/ Type Code Display Name Code System 0‑L PUL PUL TNM Edition8 UICC 0‑L OSS OSS TNM Edition8 UICC 0‑L HEP HEP TNM Edition8 UICC 0‑L BRA BRA TNM Edition8 UICC 0‑L LYM LYM TNM Edition8 UICC 0‑L OTH OTH TNM Edition8 UICC 0‑L MAR MAR TNM Edition8 UICC 0‑L PLE PLE TNM Edition8 UICC 0‑L PER PER TNM Edition8 UICC 0‑L ADR ADR TNM Edition8 UICC 0‑L SKI SKI TNM Edition8 UICC
Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

4.23 UICC/AJCC Grade 3 tiered 1.3.6.1.4.1.19376.1.3.11.29

Id	1.3.6.1.4.1.19376.1.3.11.29	Effective Date	valid from 2015‑11‑13 19:36:21
Status	Draft	Version Label
Name	UICCgrade	Display Name	UICC Grade 3 tiered
Description	Coding of the grade of differentiation (malignancy) of tumors, coded by a four-, three-, or two-tiered grading system, often using the score of a special grading system for certain tumor types
2 Source Code Systems	2.16.840.1.113883.15.16 - TNM Edition8 UICC 2.16.840.1.113883.5.1008 - Null Flavor
Level/ Type Code Display Name Code System Description 0‑L 1 G1 TNM Edition8 UICC grade 1, well (highly) differentiated 0‑L 2 G2 TNM Edition8 UICC grade 2, moderately differentiated 0‑L 3 G3 TNM Edition8 UICC grade 3, poorly differentiated 0‑L X GX TNM Edition8 UICC cannot be assessed 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.

4.24 UICC/AJCC Grade 2 tiered 1.3.6.1.4.1.19376.1.3.11.30

Id	1.3.6.1.4.1.19376.1.3.11.30	Effective Date	valid from 2015‑11‑13 19:43:09
Status	Draft	Version Label
Name	UICCgrade-2	Display Name	UICC Grade 2 tiered
Description	Coding of the grade of differentiation (malignancy) of tumors, coded by a two-tiered grading system, sometimes using the score of a special grading system for certain tumor types
2 Source Code Systems	2.16.840.1.113883.15.16 - TNM Edition8 UICC 2.16.840.1.113883.5.1008 - Null Flavor
Level/ Type Code Display Name Code System Description 0‑L L lG TNM Edition8 UICC low grade, combining grade 1 and 2 (except urothelial tumors: only grade 1) 0‑L H hG TNM Edition8 UICC low grade, combining grade 3 and 4 (except urothelial tumors: grade 2 through 4) 0‑L X X TNM Edition8 UICC cannot be assessed 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.

on Art-Decor

4.25 UICC/AJCC Grade 4 tiered 1.3.6.1.4.1.19376.1.3.11.31

Id	1.3.6.1.4.1.19376.1.3.11.31	Effective Date	valid from 2015‑11‑13 19:46:53
Status	Draft	Version Label
Name	UICCgrade-4	Display Name	UICC Grade 4 tiered
Description	Coding of the grade of differentiation (malignancy) of tumors, coded by a four-tiered grading system, sometimes using the score of a special grading system for certain tumor types.
3 Source Code Systems	2.16.840.1.113883.15.16 - TNM Edition8 UICC 1.2.276.0.76.5.336 2.16.840.1.113883.5.1008 - Null Flavor
Level/ Type Code Display Name Code System Description 0‑L 1 G1 TNM Edition8 UICC well (highly) differentiated 0‑L 2 G2 TNM Edition8 UICC moderately differentiated 0‑L 3 G3 TNM Edition8 UICC poorly differentiated 0‑L 4 G4 TNM Edition8 UICC undifferentiated resp. anaplastic 0‑L X GX TNM Edition8 UICC cannot be assessed 0‑L 0 0 1.2.276.0.76.5.336 Malignes Melanom der Konjunktiva 0‑L X X 1.2.276.0.76.5.336 nicht bestimmbar 0‑L L lG 1.2.276.0.76.5.336 Low grade (G1 oder G2) 0‑L M mG 1.2.276.0.76.5.336 intermediate (G2 oder G3) 0‑L H hG 1.2.276.0.76.5.336 high grade (G3 oder G4) 0‑L B B 1.2.276.0.76.5.336 Borderline-Malignität 0‑L U U 1.2.276.0.76.5.336 unbekannt 0‑L T T 1.2.276.0.76.5.336 trifft nicht zu 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.

on Art-Decor

4.26 UICC/AJCC Tumor Serum Markers 1.3.6.1.4.1.19376.1.3.11.32

Id	1.3.6.1.4.1.19376.1.3.11.32	Effective Date	valid from 2015‑11‑08 18:26:39
Status	Draft	Version Label
Name	UICCSerumTumorMarkers	Display Name	UICC Serum Tumor Markers
Description	Observation of serum levels of tumor markers coded for germ cell tumors
2 Source Code Systems	2.16.840.1.113883.15.16 - TNM Edition8 UICC 2.16.840.1.113883.5.1008 - Null Flavor
Level/ Type Code Display Name Code System Description 0‑L S0 S0 TNM Edition8 UICC serum tumor markers within normal limits 0‑L S1 S1 TNM Edition8 UICC LDH < 1,5* normal limit AND ßHCG< 5000mIU/ml AND AFP <1000 ng/ml 0‑L S2 S2 TNM Edition8 UICC LDH 1,5 - 10* normal limit OR ßHCG 5000 - 50000 mIU/ml OR AFP 1000 - 10000 ng/ml 0‑L S3 S3 TNM Edition8 UICC LDH >10* normal limit OR ßHCG > 50000 mIU/ml OR AFP > 10000 ng/ml 0‑L SX SX TNM Edition8 UICC No information about serum tumor markers 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.

4.27 ICD-O-3 Morphology 1.3.6.1.4.1.19376.1.3.11.33

Id	1.3.6.1.4.1.19376.1.3.11.33	Effective Date	valid from 2015‑11‑13 14:08:46
Status	Draft	Version Label	1st rev. (2013)
Name	icd-o-3-m	Display Name	ICD-O-3 Morphology
Description	International classification of diseases / oncology, morphological part for typing of benign and malignant tumors. The morphology axis provides six-digit codes ranging from 8000/0 to 9989/3. The first four digits indicate the specific histological term, i.e. morphology (8000 through 9992).&#160;<span style="text-align: justify;">In developing the previous editions and the present edition of ICD-O, a particular effort was made to use the nomenclature appearing in the World Health Organization&#160;</span> <span style="text-align: justify;">International Histological Classification of Tumours</span>&#160;<span style="text-align: justify;">series (WHO “Blue Books”)</span> <span style="text-align: justify;">7</span> <span style="text-align: justify;">. This series covers all the principal sites of cancer and includes the morphology codes of ICD-O for each neoplasm.&#160;</span>All new histological classifications or modifications have been made by the WHO / IARC in so-called "Blue Books" by &#160;2011 are listed on-line: http://codes.iarc.fr/changes.php.<br clear="none"/>The fifth digit after a slash (/) is the behavior code, which indicates whether a tumor is malignant, benign, in situ, or uncertain (whether benign or malignant). <br clear="none"/>A separate, 6th, one-digit code may also be given for histologic 4-tiered grading (differentiation) or for the cell type in lymphatic neoplasia. &#160;<br clear="none"/>The fifth and the sixth digit are coded separately in value sets 1.3.6.1.4.1.19376.1.3.11.34 and 1.3.6.1.4.1.19376.1.3.11.35
A valid code from the code system: Code System Name Code System Id Code System Version  International Classification of Diseases for Oncology, version 3. 2.16.840.1.113883.6.43.1
Or one of the following:
2 Source Code Systems	2.16.840.1.113883.6.43.1 - International Classification of Diseases for Oncology, version 3. 2.16.840.1.113883.5.1008 - Null Flavor
Level/ Type Code Code System 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.

on Art-Decor

4.28 ICD-O-3 Behavior 1.3.6.1.4.1.19376.1.3.11.34

Id	1.3.6.1.4.1.19376.1.3.11.34	Effective Date	valid from 2015‑11‑13 18:54:30
Status	Draft	Version Label	1st rev. (2013)
Name	icd-o-3-behavior	Display Name	ICD-O-3 Behavior
Description	Coding of the behavior of a tumor, coded by the first digit after slash in ICD-O-Morphology code
2 Source Code Systems	2.16.840.1.113883.6.43.1 - International Classification of Diseases for Oncology, version 3. 2.16.840.1.113883.5.1008 - Null Flavor
Level/ Type Code Display Name Code System Description 0‑L 0 /0 International Classification of Diseases for Oncology, version 3. benign 0‑L 1 /1 International Classification of Diseases for Oncology, version 3. borderline malignancy or uncertain malignant potential 0‑L 2 /2 International Classification of Diseases for Oncology, version 3. noninvasiv resp. carcinoma in situ 0‑L 3 /3 International Classification of Diseases for Oncology, version 3. invasive resp. malignant primary tumor 0‑L 6 /6 International Classification of Diseases for Oncology, version 3. metastasis resp. secondary tumor, not used in German cancer registries 0‑L 9 /9 International Classification of Diseases for Oncology, version 3. malignant, uncertain whether primary or secondary tumor, not used in German cancer registries 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.

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4.29 ICD-O-3 Differentiation 1.3.6.1.4.1.19376.1.3.11.35

Id	1.3.6.1.4.1.19376.1.3.11.35	Effective Date	valid from 2015‑11‑13 19:07:32
Status	Draft	Version Label	1st rev. (2013)
Name	icd-o-3-differentiation	Display Name	ICD-O-3 Differentiation
Description	Coding the cellular differentiation of malignant tumors, either the grade of malignancy (differentiation), or the cell line differentiation, coded by the second digit after the slash in ICD-O-3 Morphology axi
2 Source Code Systems	2.16.840.1.113883.6.43.1 - International Classification of Diseases for Oncology, version 3. 2.16.840.1.113883.5.1008 - Null Flavor
Level/ Type Code Display Name Code System Description 0‑L 1 1 International Classification of Diseases for Oncology, version 3. well (highly) differentiated 0‑L 2 2 International Classification of Diseases for Oncology, version 3. moderately differentiated 0‑L 3 3 International Classification of Diseases for Oncology, version 3. poorly differentiated 0‑L 4 4 International Classification of Diseases for Oncology, version 3. undifferentiated resp. anaplastic 0‑L 5 5 International Classification of Diseases for Oncology, version 3. T-cell differentiation in lymphomas and leukemias 0‑L 6 6 International Classification of Diseases for Oncology, version 3. B-cell differentiation, pre-B-cells, B-precursor cells in lymphomas and leukemias 0‑L 7 7 International Classification of Diseases for Oncology, version 3. Null-cell, non-B-nonT-cell differentiation in lymphomas and leukemias 0‑L 8 8 International Classification of Diseases for Oncology, version 3. NK (natural killer)-cell differentiation in lymphomas and leukemias 0‑L 9 9 International Classification of Diseases for Oncology, version 3. grading not applied, not applicable, unknown; cell type not assessed or unknown 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.

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4.30 ICD-O-3 Topography 1.3.6.1.4.1.19376.1.3.11.36

Id	1.3.6.1.4.1.19376.1.3.11.36	Effective Date	valid from 2015‑11‑13 19:16:23
Status	Draft	Version Label	1st rev. (2013)
Name	icd-o-3-topography	Display Name	ICD-O-3 Topography
Description	International classification of diseases / oncology, topographical part for typing of benign and malignant tumors. The topography axis (C-axis) uses the ICD-10 classification of malignant neoplasms (except those categories which relate to secondary neoplasms and to specified morphological types of tumours) for all types of tumours, thereby providing greater site detail for non-malignant tumours than is provided in ICD-10. In contrast to ICD-10, the ICD-O includes topography for sites of haematopoietic and reticuloendothelial tumors.
A valid code from the code system: Code System Name Code System Id Code System Version  International Classification of Diseases for Oncology, version 3. 2.16.840.1.113883.6.43.1
Or one of the following:
2 Source Code Systems	2.16.840.1.113883.6.43.1 - International Classification of Diseases for Oncology, version 3. 2.16.840.1.113883.5.1008 - Null Flavor
Level/ Type Code Code System 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.

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