1.3.6.1.4.1.19376.1.3.10.4.3/static-2015-11-29T170318

Id	1.3.6.1.4.1.19376.1.3.10.4.3	Effective Date	valid from 2015‑11‑29 17:03:18 There are versions of templates with this id: ICDO3Observation as of 2016‑10‑09 20:48:00 ICDO3Observation as of 2016‑10‑09 17:47:28 ICD-O-3TypingGrading as of 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	Closed (only defined elements are allowed)
Associated with	Associated with 1 concept Id Name Data Set psr-data​element-54 Tumor classification (ICD-O-3) APSR 2.0
Used by / Uses	Used by 8 templates, Uses 7 templates Used by Template id 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 (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 Uses Template id as Name Version 1.3.6.1.4.1.19376.1.8.1.4.2 Containment CDA author DYNAMIC 1.3.6.1.4.1.19376.1.3.10.9.1 Include X Specimen Identified DYNAMIC 1.3.6.1.4.1.19376.1.3.10.9.38 Containment ICD-O-3 Behavior (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.3.10.9.39 Containment ICD-O-3 Differentiation (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.3.10.9.40 Containment ICD-O-3 Morphology (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.3.10.9.41 Containment ICD-O-3 Topography (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.3.10.4.4 Containment Assessment Scales Observation for Scoring Systems APSR2 (2.0) DYNAMIC
Relationship	Specialization: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Example	generated example <observation classCode="OBS" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.3.10.4.3"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="59847-4" codeSystem="2.16.840.1.113883.6.1" displayName="Histology and behavior ICD-O-3"/>  <text/>  <effectiveTime>     <low value="20161125150843"/>  </effectiveTime>  <value xsi:type="CV" code="C50.38500/32" 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' (dynamic) -->   </author>  <specimen>     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) -->   </specimen>  <entryRelationship typeCode="SPRT">     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.38 'ICD-O-3 Behavior' (dynamic) -->   </entryRelationship>  <entryRelationship typeCode="SPRT">     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.39 'ICD-O-3 Differentiation' (dynamic) -->   </entryRelationship>  <entryRelationship typeCode="SPRT">     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.40 'ICD-O-3 Morphology' (dynamic) -->   </entryRelationship>  <entryRelationship typeCode="SPRT">     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.41 'ICD-O-3 Topography' (dynamic) -->   </entryRelationship>  <entryRelationship typeCode="SPRT">     <!-- template 1.3.6.1.4.1.19376.1.3.10.4.4 'Assessment Scales Observation for Scoring Systems APSR2' (dynamic) -->   </entryRelationship></observation>
Item DT Card Conf Description Label hl7:observation 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 @classCode cs 0 … 1 F OBS @moodCode cs 1 … 1 F EVN 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 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 hl7:code CD CWE 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3   CONF @code shall be "59847-4" @codeSystem shall be "2.16.840.1.113883.6.1" @displayName shall be "Histology and behavior ICD-O-3" @codeSystemName shall be "LOINC" or @code shall be "397005006" @codeSystem shall be "2.16.840.1.113883.6.96" @displayName shall be "WHO tumor classification (observable entity)" @codeSystemName shall be "SNOMED-CT" hl7:derivationExpr ST NP PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 hl7:text ED 0 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3   Example <text> ICD-O-3: C50.3L_8500/32</text> hl7:effectiveTime IVL_TS 0 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 hl7:value CV 0 … 1 R Combined topography and morphology axis code. A complete code consists of 10 digits (4 for topography, 6 for morphology, behavior and grading), separated by a "." after the 3rd digit in topography and a "/" after the 4th digit in morphology (8th digit in total). Qualifier for laterality (1 additional digit) may be given after the topography code. PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 @code CONF 1 … 1 F combined code from ICD-O-3 morphology and topography axis @codeSystem 1 … 1 F 2.16.840.1.113883.6.43.1 (International Classification of Diseases for Oncology, version 3.) @codeSystemName 1 … 1 F ICD-O-3   Associated with concepts: psr-data​element-54 Tumor classification (ICD-O-3) APSR 2.0   Example invasive breast cancer, NST, moderately differentiated <value xsi:type="CV" code="C50.38500/32" codeSystem="2.16.840.1.113883.6.43.1"/> hl7:author 0 … 1 R Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 Included 1 … * R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC) hl7:specimen 1 … * R Required when more than one specimen is documented at this level. This is often the case in APSR. PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified @typeCode cs 0 … 1 F SPC   Associated with concepts: psr-data​element-17 Specimen identification APSR 2.0 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   Associated with concepts: psr-data​element-68 Tissue section ID APSR 2.0 psr-data​element-98 Specimen ID APSR 2.0 psr-data​element-66 Part ID APSR 2.0 psr-data​element-67 Block ID APSR 2.0 psr-data​element-95 Parent ID APSR 2.0 hl7:entryRelationship 0 … 1 R 5th digit in the morphology code Contains 1.3.6.1.4.1.19376.1.3.10.9.38 ICD-O-3 Behavior (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 @typeCode cs 1 … 1 F SPRT hl7:entryRelationship 0 … 1 R 6th digit in the morphology code Contains 1.3.6.1.4.1.19376.1.3.10.9.39 ICD-O-3 Differentiation (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 @typeCode cs 1 … 1 F SPRT hl7:entryRelationship 0 … 1 R First four digits in the morphology code Contains 1.3.6.1.4.1.19376.1.3.10.9.40 ICD-O-3 Morphology (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 @typeCode cs 1 … 1 F SPRT hl7:entryRelationship 0 … 1 R Code from topography axis, optionally qualified by laterality Contains 1.3.6.1.4.1.19376.1.3.10.9.41 ICD-O-3 Topography (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 @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 (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3 @typeCode cs 1 … 1 F SPRT