1.3.6.1.4.1.19376.1.8.1.2.1/static-2014-05-13T143808

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Id1.3.6.1.4.1.19376.1.8.1.2.1Effective Date valid from 2014‑05‑13 14:38:08
StatusKyellow.png DraftVersion Label2.0
NameClinicalInformationSectionDisplay NameClinical 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).
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.1
LabelPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
ClassificationCDA Section Level Template
Open/ClosedClosed (only defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 5 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.1.1ContainmentKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA authorDYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.1ContainmentKgreen.png IHE Reason for Referral Section (2014)DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.4ContainmentKorange.png History of Present Illness Section (2.1)DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.6ContainmentKgreen.png IHE Active Problems Section (2014)DYNAMIC
RelationshipSpecialization: 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' (dynamic) -->
  </entry>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) 0..* C -->
  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.1 'IHE Reason for Referral Section' (dynamic) -->
  </component>  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.4 'History of Present Illness Section' (dynamic) -->
  </component>  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.6 'IHE Active Problems Section' (dynamic) -->
  </component></section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … 1RPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.png@moodCode
cs0 … 1FEVN
 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.

Treetree.pnghl7:templateId
II1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.1
Treetree.pnghl7:code
CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Treeblank.pngTreetree.png@code
CONF1 … 1F22636-5
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@displayName
1 … 1FPathology report relevant history
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treetree.pnghl7:title
ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
 CONF
element content shall be "CLINICAL INFORMATION SECTION"
 Example<title>CLINICAL INFORMATION</title>
Treetree.pnghl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
 Example<text> Tissue submitted: left breast biopsy and apical axillary tissue </text>
Treetree.pnghl7:language​Code
CS0 … 1PaLM 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)
Treetree.pnghl7:entry
ANY0 … *RProblem 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
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Included0 … *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
Treetree.pnghl7:author
0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.png@typeCode
cs0 … 1FAUT
Treeblank.pngTreetree.png@context​Control​Code
cs0 … 1FOP
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor></author>
Treeblank.pngTreetree.pnghl7:functionCode
CE0 … 1PaLM 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)
Treeblank.pngTreetree.pnghl7:time
TS.​DATE.​MIN1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
1 … 1MPaLM 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treetree.pnghl7:component
0 … 1Subsection

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
Treetree.pnghl7:component
0 … 1Subsection


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
Treetree.pnghl7:component
0 … 1Subsection

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 (DYNAMIC)		PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
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