Item | DT | Card | Conf | Description | Label |
---|
| | 0 … * | R | | (Assessm… |
 | @classCode
|
| cs | 1 … 1 | F | OBS |
 | @moodCode
|
| cs | 1 … 1 | F | EVN |
 | @negationInd
|
| bl | 0 … 1 | | |
 | hl7:templateId
|
| II | 1 … 1 | M | | (Assessm… |
 |  | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.3.10.9.43 |
 | hl7:id
|
| II | 0 … * | R | | (Assessm… |
 | hl7:code
|
| CE CWE | 1 … 1 | M | | (Assessm… |
| CONF | shall be drawn from concept domain "<<395527009 | Microscopic specimen observable (observable entity) |" |
|
| Example | for use case #1, Breast tubule formation <code code="371470008" codeSystem="2.16.840.1.113883.6.96"/> |
 | hl7:text
|
| ED | 0 … 1 | R | | (Assessm… |
 | hl7:statusCode
|
| CS CNE | 1 … 1 | M | | (Assessm… |
| Constraint | The observation statusCode is “completed” if the observation was actually performed and has produced a result in the value element. In other cases the status of the intended observation is “aborted” and the result will never come.
|
| CONF | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC) |
|
 | hl7:effectiveTime
|
| IVL_TS | 0 … 1 | R | | (Assessm… |
 | hl7:value
|
| INT | 0 … 1 | R | Single numerical score item of a scoring system, e.g. "2" for Breast tubule formation | (Assessm… |
| Example | for use case #1 <value value="2"/> |
 | hl7:interpretationCode
|
| CE CWE | 0 … 1 | R | | (Assessm… |
| CONF | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 Observation Interpretation (HL7) (DYNAMIC) |
|
 | hl7:referenceRange
|
| | 0 … 1 | R | | (Assessm… |
 |  | @typeCode
|
| cs | 1 … 1 | F | REVF |
 |  | hl7:observationRange
|
| | 0 … 1 | R | | (Assessm… |
| cs | 1 … 1 | F | OBS |
| cs | 1 … 1 | F | EVN.CRT |
| CD CWE | 1 … 1 | R | | (Assessm… |
| CONF | 1 … 1 | F | 2.16.840.1.113883.5.4 (Act Code) |
| ED | 0 … 1 | R | | (Assessm… |
| TS | 0 … 1 | R | | (Assessm… |
| ANY | 1 … 1 | R | | (Assessm… |
| CD CWE | 0 … 1 | R | | (Assessm… |
| CONF | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 Observation Interpretation (HL7) (DYNAMIC) |
|
Included | 0 … * | R | from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC) |
 | hl7:specimen
|
| | 0 … * | R | Required in XD-LAB when more than one specimen is documented at this level. Always required in APSR.
| PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified |
 |  | @typeCode
|
| cs | 0 … 1 | F | SPC |
 |  | hl7:specimenRole
|
| | 1 … 1 | M | | PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified |
| cs | 0 … 1 | F | SPEC |
| II | 1 … 1 | R | Specimen ID, coming from the LIS | PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified |
 | hl7:performer
|
| | 0 … * | C | Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC) | (Assessm… |
 | hl7:author
|
| | 0 … * | C | Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (DYNAMIC) | (Assessm… |
 | hl7:informant
|
| | 0 … * | R | Contains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (DYNAMIC) | (Assessm… |