1.3.6.1.4.1.19376.1.3.10.3.1/static-2016-11-13T142808

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Id1.3.6.1.4.1.19376.1.3.10.3.1Effective Date valid from 2016‑11‑13 14:28:08
StatusKyellow.png DraftVersion Label2.0
NameAdditionalSpecifiedObservationSectionDisplay NameAdditional Specified Observation Section
DescriptionTemplate 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. The only entry for this section is the Problem Organizer Entry module.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.3.1
LabelPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 1 concept
IdNameData Set
psr-data​element-96Additional Specified ObservationAPSR 2.0
Used by / Uses
Used by 1 template, Uses 3 templates
Used by Template id as NameVersion
1.3.6.1.4.1.19376.1.8.1.1.1ContainmentKyellow.png Anatomic Pathology Structured Report (2.0)2014‑05‑13 11:57:57
Uses Template id as NameVersion
2.16.840.1.113883.10.12.318ContainmentKgreen.png CDA Author (Body)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)DYNAMIC
RelationshipAdaptation: 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"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="57025-9" displayName="Data Criteria section" codeSystem="2.16.840.1.113883.6.1"/>  <title/>  <text/>  <languageCode code="aa"/>  <author>
    <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' (dynamic) -->
  </author>  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (dynamic) -->
  </informant>  <entry typeCode="COMP" contextConductionInd="true">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (dynamic) -->
  </entry></section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … *RPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.png@moodCode
cs0 … 1FEVN
 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 does not contain any subsections. 

 Target.pngAssociated with concepts:
psr-data​element-96Additional Specified ObservationAPSR 2.0
Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.3.1
Treetree.pnghl7:id
II0 … 1PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Treetree.pnghl7:code
CE1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
 ConstraintThe LOINC code SHALL be chosen according the specified observation type
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10871 DocumentSectionType (DYNAMIC)
or
@code shall be "xxxxx-x"
@codeSystem shall be "2.16.840.1.113883.6.1"
@displayName shall be "specified observation"
@codeSystemName shall be "LOINC"
Treetree.pnghl7:title
ST1 … 1RTitle of the specified observationPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
 Example
MP observation
<text>Molecular Pathology observation</text>
Treetree.pnghl7:text
SD.TEXT1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Treetree.pnghl7:language​Code
CS0 … 1PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
Treetree.pnghl7:author
0 … *Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2

Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)		PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Treetree.pnghl7:informant
0 … *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 (DYNAMIC)		PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Treetree.pnghl7:entry
0 … *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 (DYNAMIC)		PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
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