| Item | DT | Card | Conf | Description | Label |
|---|
| | 0 … 1 | R | Five digits of Morphology (and Behavior) code axis, supported by Differentiation code | PaLM…-O-3 |
 | @classCode
|
| cs | 1 … 1 | F | OBS |
| @moodCode
|
| cs | 1 … 1 | F | EVN |
| @negationInd
|
| bl | 0 … 1 | | |
| hl7:templateId
|
| II | 1 … 1 | M | | PaLM…-O-3 |
 | | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.3.10.4.3 |
| hl7:id
|
| II | 0 … 1 | R | | PaLM…-O-3 |
| hl7:code
|
| CD CWE | 1 … 1 | M | | PaLM…-O-3 |
| | CONF | | @code shall be "59847-4" | | @codeSystem shall be "2.16.840.1.113883.6.1" | | @codeSystemName shall be "LOINC" | | @displayName shall be "Histology and behavior ICD-O-3" | | or | | @code shall be "397005006" | | @codeSystem shall be "2.16.840.1.113883.6.96" | | @codeSystemName shall be "SNOMED-CT" | | @displayName shall be "WHO tumor classification (observable entity)" |
|
| hl7:originalText
|
| ED | 0 … 1 | R | Original text of the Morphology (and Behavior) code with supporting Differentiation code
| PaLM…-O-3 |
| | Example | for use case #1 <text>8500/31</text> |
| hl7:statusCode
|
| CS CNE | 1 … 1 | M | | PaLM…-O-3 |
| | CONF | | The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 ActStatusAbortedCompleted (DYNAMIC) |
|
| hl7:effectiveTime
|
| IVL_TS | 1 … 1 | M | | PaLM…-O-3 |
| hl7:value
|
| CD | 1 … 1 | R | Morphology axis code. A complete code consists of 6 digits (for morphology, behavior and grading), the latter both separated by "/" after the 4th digit in morphology.
Behavior and differentiation are coded as sub-observations | PaLM…-O-3 |
| | CONF | | The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.33 ICD-O-3 Morphology and Behavior (DYNAMIC) |
|
| | Example | for use case #1: invasive breast cancer, NST, well differentiated <value xsi:type="CD" code="8500/3" codeSystem="2.16.840.1.113883.6.43.1"/> |
| 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) | PaLM…-O-3 |
| hl7:author
|
| II | 0 … 1 | C | Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (DYNAMIC) | PaLM…-O-3 |
| 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) | PaLM…-O-3 |
| 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) | PaLM…-O-3 |
| Included | 1 … * | R | from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC) |
| hl7:specimen
|
| | 1 … * | 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 … 1 | C | 5th digit in the morphology code, used only if this digit is deviant from the code list in morphology axis
Contains 1.3.6.1.4.1.19376.1.3.10.9.38 ICD-O-3 Behavior (DYNAMIC) | PaLM…-O-3 |
| | @typeCode
|
| cs | 1 … 1 | F | SPRT |
| hl7:entryRelationship
|
| | 0 … 1 | R | 6th digit in the morphology code
Contains 1.3.6.1.4.1.19376.1.3.10.9.39 ICD-O-3 Differentiation (DYNAMIC) | PaLM…-O-3 |
| | @typeCode
|
| cs | 1 … 1 | F | SPRT |
| hl7:entryRelationship
|
| | 0 … 1 | R | optional grading by a scoring system, e.g. by means of the Elston-Ellis-Scoring-System in case of invasive breast cancer (ICD-O C50)
Contains 1.3.6.1.4.1.19376.1.3.10.4.4 Assessment Scales Observation for Scoring Systems APSR2 (DYNAMIC) | PaLM…-O-3 |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| hl7:reference
|
| | 0 … * | R | Contains 2.16.840.1.113883.10.12.324 CDA Reference (DYNAMIC) | PaLM…-O-3 |
Draft
