1.3.6.1.4.1.19376.1.8.1.2.1/static-2014-05-13T143808

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	Closed (only defined elements are allowed)
Associated with	Associated with 4 concepts Id Name Data Set psr-data​element-40 Clinical Information APSR 2.0 psr-data​element-43 Clinical Problem APSR 2.0 psr-data​element-42 History of Present Illness APSR 2.0 psr-data​element-41 Reason for Referral APSR 2.0
Used by / Uses	Used by 1 template, Uses 5 templates Used by Template id as Name Version 1.3.6.1.4.1.19376.1.8.1.1.1 Containment Anatomic Pathology Structured Report (2.0) 2014‑05‑13 11:57:57 Uses Template id as Name Version 1.3.6.1.4.1.19376.1.8.1.3.6 Containment Problem Organizer (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.4.2 Include CDA author DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.1 Containment IHE Reason for Referral Section (2014) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.4 Containment History of Present Illness Section (2.1) DYNAMIC 1.3.6.1.4.1.19376.1.5.3.1.3.6 Containment CDA Active Problems Section (2.0) DYNAMIC
Relationship	Specialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example	Example <section classCode="DOCSECT" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.8.1.2.1"/>  <code code="22636-5" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report relevant history"/>  <title/>  <text/>  <languageCode/>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' 0..* C(dynamic) -->   </author>  <component>     <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' 0..* R(dynamic) -->   </component>  <component>     <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.1 'Reason for Referral Section (V2)' 0..1 R(dynamic) -->   </component>  <component>     <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.4 'History of Present Illness Section' 0..1 R (dynamic) -->   </component>  <component>     <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.6 'CDA Active Problems Section' 0..1 R(dynamic) -->   </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 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 among the list described below in table 6.2.4.1.3-1, 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.   Associated with concepts: psr-data​element-40 Clinical Information APSR 2.0 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) @displayName 1 … 1 F Pathology report relevant history @codeSystemName 1 … 1 F LOINC hl7:title ST 1 … 1 R PaLM Suppl. 2.0‑3: 6.3.4.1 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 (DYNAMIC) hl7:entry ANY 0 … * R Problem organizer Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (DYNAMIC) PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section @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 (DYNAMIC) 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 0 … 1 F AUT @context​Control​Code cs 0 … 1 F OP   Associated with concepts: psr-data​element-4 Pathologist APSR 2.0 psr-data​element-79 Device APSR 2.0   Example author is a person <author typeCode="AUT" contextControlCode="OP">   <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">     <!-- ... -->   </assignedAuthor></author> hl7:functionCode CE 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC) hl7:time TS.​DATE.​MIN 1 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assignedAuthor 1 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F ASSIGNED hl7:id II 1 … * 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 hl7:telecom TEL 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Choice 1 … 1 Elements to choose from: hl7:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person  … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Included 0 … * from 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC) @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  … 1 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 1 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:softwareName SC 1 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:represented​Organization 1 … 1 M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author   Example author is a device <representedOrganization classCode="ORG" determinerCode="INSTANCE">   <name>     <!-- ... -->   </name></representedOrganization> Included from 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC) @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 1 … 1 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 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:component 0 … 1 R 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 (DYNAMIC) PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section   Associated with concepts: psr-data​element-41 Reason for Referral APSR 2.0 hl7:component 0 … 1 R Subsection Source: PCC TF-2: 6.3.3.2.1 Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (DYNAMIC) PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section   Associated with concepts: psr-data​element-42 History of Present Illness APSR 2.0 hl7:component 0 … 1 R Subsection Source: PCC TF-2: 6.3.3.2.3 Contains 1.3.6.1.4.1.19376.1.5.3.1.3.6 CDA Active Problems Section (DYNAMIC) PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section   Associated with concepts: psr-data​element-43 Clinical Problem APSR 2.0