| Item | DT | Card | Conf | Description | Label |
|---|
| | 0 … 1 | R | | PaLMales |
 | @classCode
|
| cs | 0 … 1 | F | OBS |
| @moodCode
|
| cs | 1 … 1 | F | EVN |
| @negationInd
|
| bl | 0 … 1 | | |
| hl7:templateId
|
| II | 1 … 1 | M | | PaLMales |
 | | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.3.10.4.4 |
| hl7:id
|
| II | 0 … * | R | | PaLMales |
| hl7:code
|
| CE CWE | 1 … 1 | M | Assessment scale, e.g. grading by scoring | PaLMales |
| | CONF | | @code shall be "273249006" | | @codeSystem shall be "2.16.840.1.113883.6.96" | | @codeSystemName shall be "SCT" | | @displayName shall be "Assessment scales" | | or | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19918 ActCoverageAssessmentObservationValue (DYNAMIC) |
|
| | Example | for use case #1 <code code="273249006" codeSystem="2.16.840.1.113883.6.96" displayName="Assessment scales (assessment scale)"/> |
| hl7:derivationExpr
|
| ST | 0 … 1 | R | This optional field can be used to specify how the total score is calculated. In most cases the total score will be the sum of its components. But complex mathematical functions and/or logical operations are possible as well.
| PaLMales |
| hl7:text
|
| ED | 0 … 1 | R | | PaLMales |
| | Example | for use case #1 <text>Nottingham combined grad I (1 of 3)</text> |
| hl7:statusCode
|
| CS | 1 … 1 | M | | PaLMales |
| | 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 | 1 … 1 | M | | PaLMales |
| hl7:priorityCode
|
| CE | 0 … 1 | | | PaLMales |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC) |
|
| hl7:repeatNumber
|
| IVL_INT | 0 … 1 | | | PaLMales |
| hl7:value
|
| ANY | 1 … * | R | any total value of a scoring systems, e.g. Gleason score, van Nuys score, etc., either with data type INT or with data type CD or CO
| PaLMales |
| | Example | for use case #1, Nottingham combined grade I <value value="1"/> |
| hl7:interpretationCode
|
| CE | 0 … * | R | | PaLMales |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC) |
|
| hl7:methodCode
|
| CE | 0 … * | R | | PaLMales |
| | @code
|
| CONF | 0 … 1 | F | 0114 |
| | @codeSystem
|
| 0 … 1 | F | 2.16.840.1.113883.1.11.14079 |
| | @codeSystemName
|
| 0 … 1 | F | HL7 |
| | @displayName
|
| 0 … 1 | F | Microscopy, Light |
| hl7:performer
|
| II | 0 … 1 | C | Performing lab
Source: PaLM TF-3: 6.3.2.20
Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC) | PaLMales |
| | Constraint | The performing laboratory is present at this level only if this particular observation was performed by a (subcontractor) laboratory distinct from the one issuing the rest of the observations in this organizer.
|
| hl7:author
|
| II | 0 … * | C | Author
Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.2
Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (DYNAMIC) | PaLMales |
| hl7:informant
|
| II | 0 … * | R | Informant
Source: PaLM TF 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) | PaLMales |
| hl7:participant
|
| II | 0 … * | R | Additional participants
Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.6
Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry APSR (Body) (DYNAMIC) | PaLMales |
| 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:entryRelationship
|
| | 0 … * | R | Contains 1.3.6.1.4.1.19376.1.3.10.9.42 Assessment Scoring System APSR 2.0 (DYNAMIC) | PaLMales |
| where [hl7:observation [hl7:code [(@code='246262008 or
Score (attribute) or
' and @codeSystem='2.16.840.1.113883.6.96')]]] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | SPRT |
| | hl7:sequenceNumber
|
| INT | 0 … 1 | | | PaLMales |
| hl7:reference
|
| | 0 … * | R | Contains 2.16.840.1.113883.10.12.324 CDA Reference (DYNAMIC) | PaLMales |
| hl7:referenceRange
|
| | 0 … * | R | | PaLMales |
| | @typeCode
|
| cs | 1 … 1 | F | REFV |
| | hl7:observationRange
|
| | 1 … 1 | R | | PaLMales |
| cs | 0 … 1 | F | OBS |
| cs | 0 … 1 | F | EVN.CRT |
| CD | 0 … 1 | | | PaLMales |
| CONF | 0 … 1 | F | 2.16.840.1.113883.5.4 (Act Code) |
| ED | 0 … 1 | | | PaLMales |
| ANY | 0 … 1 | | | PaLMales |
| CE | 0 … 1 | | | PaLMales |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC) |
|
Draft
