| Item | DT | Card | Conf | Description | Label |
|---|
| | 0 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section |
| | Constraint | This section SHALL contain a code element populated with these attributes: @code="22635-7" @codeSystem="2.16.840.1.113883.6.1" @displayName="Pathology report microscopic observation" 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 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. |
 | hl7:templateId
|
| II | 1 … 1 | M | | PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section |
 | | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.8.1.2.4 |
| hl7:code
|
| CE | 1 … 1 | M | | PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section |
| | @code
|
| CONF | 1 … 1 | F | 22635-7 |
| | @codeSystem
|
| 1 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) |
| | @displayName
|
| 1 … 1 | F | Pathology report microscopic observation |
| | @codeSystemName
|
| 1 … 1 | F | LOINC |
| hl7:title
|
| ST | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section |
| | CONF | | element content shall be "MICROSCOPIC OBSERVATION SECTION" |
|
| | Example | <title>MICROSCOPIC OBSERVATION SECTION</title> |
| hl7:text
|
| SD.TEXT | 1 … 1 | M | | PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section |
| | Example | <text> Sections of part #1 confirm frozen section diagnosis of infiltrating duct carcinoma. It is to be noted that the tumor cells show considerable pleomorphism, and mitotic figures are frequent (as many as 4 per high power field). Total size of primary tumor is estimated to be 3cm in greatest dimension. Many foci of calcification are present within the tumor. Part #2 consists of fibrofatty tissue and includes 18 lymph nodes. All lymph nodes are free of disease with the exception of one lymph node, which contains several micrometastases. </text> |
| Included | 0 … * | C | from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (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 |
| | @contextControlCode
|
| cs | 0 … 1 | F | OP |
| | Example | author is a person <author typeCode="AUT" contextControlCode="OP">
<time value="201306101654"/> <assignedAuthor classCode="ASSIGNED">
<!-- ... -->
</assignedAuthor></author> |
| | hl7:functionCode
|
| CE CWE | 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 (2014‑03‑26) |
|
| | hl7:templateId
|
| | 1 … 1 | M | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.8.1.4.2 |
| | hl7:time
|
| TS | 1 … 1 | M | The authoring time is the date & time that this author contributed to the document. It SHALL be provided. | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | hl7:assignedAuthor
|
| | 0 … 1 | C | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| cs | 0 … 1 | F | ASSIGNED |
| II | 1 … 1 | M | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| AD | 1 … 1 | M | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| TEL | 1 … 1 | M | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| Choice | 1 … 1 | | The author is either an assigned person or an authoring device.
Elements to choose from:- hl7:assignedPerson
- hl7:assignedAuthoringDevice
|
| | 0 … 1 | C | | 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)
The name(s) SHALL be given. |
| | 0 … 1 | F | PSN |
| | 0 … 1 | F | INSTANCE |
| PN | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | | | hl7:assignedAuthoringDevice
|
| | 0 … 1 | C | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| cs | 0 … 1 | F | DEV |
| cs | 0 … 1 | F | INSTANCE |
| | | | | hl7:manufacturerModelName
|
| SC | 0 … 1 | R | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| SC | 0 … 1 | R | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| CE | 0 … 1 | R | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | | hl7:representedOrganization
|
| | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | Example | represented organization for author as a device <representedOrganization classCode="ORG" determinerCode="INSTANCE">
<name>
<!-- ... -->
</name></representedOrganization> |
| Included | 0 … 1 | | from 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC)
The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given. |
| | 0 … 1 | F | ORG |
| | 0 … 1 | F | INSTANCE |
| II | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| ON | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| TEL | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| AD | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| hl7:entry
|
| | 0 … * | R | Problem organizer entry
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: 6.3.4.4 Microscopic observation section |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
Draft
