1.3.6.1.4.1.19376.1.3.10.9.42/static-2016-10-10T113336

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Id1.3.6.1.4.1.19376.1.3.10.9.42Effective Date valid from 2016‑10‑10 11:33:36
StatusKyellow.png DraftVersion Label2.0
NameAssessmentScoringSystemAPSR2.0Display NameAssessment Scoring System APSR 2.0
DescriptionTemplate CDA Observation (prototype, directly derived from PO.0CD_RM000040 MIF)

Supportive Observation entry for describing a scoring system
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.42
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 10 templates, Uses 4 templates
Used by Template id as NameVersion
1.3.6.1.4.1.19376.1.3.10.4.4ContainmentKyellow.png Assessment Scales Observation for Scoring Systems APSR2 (2.0)2016‑10‑06 13:12:00
1.3.6.1.4.1.19376.1.3.10.4.3Link.pngKyellow.png ICD-O-3 Typing and Grading Observation (2.0)2015‑11‑29 17:03:18
1.3.6.1.4.1.19376.1.8.1.3.6Link.pngKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.3.10.3.1Link.pngKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.1Link.pngKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2Link.pngKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3Link.pngKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4Link.pngKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5Link.pngKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
Uses Template id as NameVersion
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen IdentifiedDYNAMIC
1.3.6.1.4.1.19376.1.3.10.9.43ContainmentKyellow.png Assessment Scoring Item APSR 2.0 (2.0)DYNAMIC
2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA ReferenceDYNAMIC
2.16.840.1.113883.10.12.329ContainmentKgreen.png CDA PreconditionDYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Example
generated example for use case #1
<observation negationInd="false" classCode="OBS" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.9.42"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="246262008 | Score (attribute) |" codeSystem="2.16.840.1.113883.6.96" displayName="Score"/>  <derivationExpr/>  <text/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20170224134516"/>  </effectiveTime>
  <value code="372276001" codeSystem="2.16.840.1.113883.6.96" displayName="Nottingham Combined Grade (observable entity)"/>  <methodCode code="0107" displayName="Microscopy" codeSystem="2.16.840.1.113883.5.84"/>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 1..* R -->
  <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">
    <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.43 'Assessment Scoring Item APSR 2.0' (dynamic) -->
  </entryRelationship>
  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (dynamic) -->
  </reference>
  <precondition>
    <!-- template 2.16.840.1.113883.10.12.329 'CDA Precondition' (dynamic) -->
  </precondition>
  <referenceRange typeCode="REFV">
    <observationRange classCode="OBS" moodCode="EVN.CRT">
      <code code="--code--" codeSystem="2.16.840.1.113883.5.4"/>      <text/>      <value xsi:type="ANY"/>      <interpretationCode code="CAR" displayName="Carrier" codeSystem="2.16.840.1.113883.5.83"/>    </observationRange>
  </referenceRange>
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … 1R(AssessmentScoringSystemAPSR2.0)
Treetree.png@classCode
cs0 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1M(AssessmentScoringSystemAPSR2.0)
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.9.42
Treetree.pnghl7:id
II0 … *(AssessmentScoringSystemAPSR2.0)
Treetree.pnghl7:code
CV CWE1 … 1R(AssessmentScoringSystemAPSR2.0)
Treeblank.pngTreetree.png@code
CONF1 … 1 @code shall be out of choice:
  • 246262008
  • Score (attribute)
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.96 (SNOMED Clinical Terms)
Treeblank.pngTreetree.png@displayName
1 … 1FScore
Treeblank.pngTreetree.png@codeSystemName
1 … 1FSCT
Treetree.pnghl7:derivationExpr
ST0 … 1This 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.
(AssessmentScoringSystemAPSR2.0)
Treetree.pnghl7:text
ED0 … 1Scoring system used(AssessmentScoringSystemAPSR2.0)
Treetree.pnghl7:statusCode
CS CNE1 … 1R(AssessmentScoringSystemAPSR2.0)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS0 … 1R(AssessmentScoringSystemAPSR2.0)
Treetree.pnghl7:value
CE CWE1 … 1R(AssessmentScoringSystemAPSR2.0)
 CONF
@code shall be "any codes from 395531003 | Tumor observable (observable entity) |"
@codeSystem shall be "2.16.840.1.113883.6.96"
@displayName shall be "any score systems from Tumor observables"
@codeSystemName shall be "SCT"
or
@code shall be "any codes from 273249006 | Assessment scales"
@codeSystem shall be "2.16.840.1.113883.6.96"
@displayName shall be "any score systems from Assessment scales"
@codeSystemName shall be "SCT"
Treetree.pnghl7:methodCode
CE0 … *(AssessmentScoringSystemAPSR2.0)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (DYNAMIC)
Included1 … *R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC)
Treetree.pnghl7:specimen
1 … *RRequired 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
Treeblank.pngTreetree.png@typeCode
cs0 … 1FSPC
 Target.pngAssociated with concepts:
psr-data​element-17Specimen identificationAPSR 2.0
Treeblank.pngTreetree.pnghl7:specimenRole
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FSPEC
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
 Target.pngAssociated with concepts:
psr-data​element-68Tissue section IDAPSR 2.0
psr-data​element-98Specimen IDAPSR 2.0
psr-data​element-66Part IDAPSR 2.0
psr-data​element-67Block IDAPSR 2.0
psr-data​element-95Parent IDAPSR 2.0
Treetree.pnghl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.10.9.43 Assessment Scoring Item APSR 2.0 (DYNAMIC)(AssessmentScoringSystemAPSR2.0)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treeblank.pngTreetree.png@inversionInd
bl0 … 1 
Treeblank.pngTreetree.png@negationInd
bl0 … 1 
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1(AssessmentScoringSystemAPSR2.0)
Treeblank.pngTreetree.pnghl7:seperatableInd
BL0 … 1(AssessmentScoringSystemAPSR2.0)
Treetree.pnghl7:reference
0 … *Contains 2.16.840.1.113883.10.12.324 CDA Reference (DYNAMIC)(AssessmentScoringSystemAPSR2.0)
Treetree.pnghl7:precondition
0 … *Contains 2.16.840.1.113883.10.12.329 CDA Precondition (DYNAMIC)(AssessmentScoringSystemAPSR2.0)
Treetree.pnghl7:referenceRange
0 … *(AssessmentScoringSystemAPSR2.0)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFV
Treeblank.pngTreetree.pnghl7:observationRange
1 … 1R(AssessmentScoringSystemAPSR2.0)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FOBS
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs0 … 1FEVN.CRT
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CD0 … 1R(AssessmentScoringSystemAPSR2.0)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF1 … 1F2.16.840.1.113883.5.4 (Act Code)
Treeblank.pngTreeblank.pngTreetree.pnghl7:text
ED0 … 1R(AssessmentScoringSystemAPSR2.0)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
ANY0 … 1R(AssessmentScoringSystemAPSR2.0)
Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretationCode
CE0 … 1(AssessmentScoringSystemAPSR2.0)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 Observation Interpretation (HL7) (DYNAMIC)