1.3.6.1.4.1.19376.1.8.1.2.3/static-2014-05-13T115709

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	Closed (only defined elements are allowed)
Associated with	Associated with 2 concepts Id Name Data Set psr-data​element-30 Macroscopic observation APSR 2.0 psr-data​element-31 macroscopic observation text APSR 2.0
Used by / Uses	Used by 1 template, Uses 2 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 Content Module (2.0) 2014‑05‑13 11:57:57 Uses Template id as Name Version 1.3.6.1.4.1.19376.1.8.1.4.2 Include CDA author DYNAMIC 1.3.6.1.4.1.19376.1.8.1.3.6 Containment Problem Organizer (2.0) DYNAMIC
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</title>  <text/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) 0..* C -->   <entry typeCode="COMP">     <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (dynamic) -->   </entry>  <component typeCode="COMP">     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (dynamic) -->   </component></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.   Associated with concepts: psr-data​element-30 Macroscopic observation APSR 2.0 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) @displayName 1 … 1 F Pathology report gross observation @codeSystemName 1 … 1 F LOINC 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"   Example <title>Macroscopic Observation</title> hl7:text SD.TEXT 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section   Associated with concepts: psr-data​element-31 macroscopic observation text APSR 2.0   Example <text> Part #1 is labeled “left breast biopsy” and is received fresh after frozen section preparation. It consists of a single firm nodule measuring 3cm in circular diameter and 1.5cm in thickness surrounded by adherent fibrofatty tissue. On section a pale gray, slightly mottled appearance is revealed. Numerous sections are submitted for permanent processing. Part #2 is labeled "apical left axillary tissue" and is received fresh. It consists of two amorphous fibrofatty tissue masses without grossly discernible lymph nodes therein. Both pieces are rendered into numerous sections and submitted in their entirety for history. </text> Included 0 … * C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author (DYNAMIC) 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 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: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 (DYNAMIC) PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true