1.3.6.1.4.1.19376.1.3.10.9.43/static-2016-10-11T102617: Unterschied zwischen den Versionen

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<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.9.43</td><th style="width: 20em; text-align: left;">Effective Date</th><td style="text-align: left;"> valid from 2016‑10‑11 10:26:17</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|16px]] Draft</td><th style="width: 20em; text-align: left;">Version Label</th><td style="text-align: left;">2.0</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">AssessmentScoringItemAPSR2.0</td><th style="width: 20em; text-align: left;">Display Name</th><td style="text-align: left;">Assessment Scoring Item APSR 2.0</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Description</th><td style="text-align: left;" colspan="3">Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF)<br /><br />Supportive Observation entry template for describing the granular Items for a scoring system, e.g.Elston-Ellis-Score or Gleason Score</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Context</th><td style="text-align: left;" colspan="3">Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.43</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Classification</th><td style="text-align: left;" colspan="3">CDA Entry Level Template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Open/Closed</th><td style="text-align: left;" colspan="3">Open (other than defined elements are allowed)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Used by / Uses</th><td style="text-align: left;" colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Used by 11 templates, Uses 6 templates</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Used by Template id</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.9.42</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Assessment Scoring System APSR 2.0 (2.0)</td><td style="text-align: left;">2016‑10‑10 11:33:36</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.4.4</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Assessment Scales Observation for Scoring Systems APSR2 (2.0)</td><td style="text-align: left;">2016‑10‑06 13:12:00</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.4.3</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] ICD-O-3 Typing and Grading Observation (2.0)</td><td style="text-align: left;">2015‑11‑29 17:03:18</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.3.6</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Problem Organizer (2.0)</td><td style="text-align: left;">2015‑08‑13 10:24:55</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.3.1</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Additional Specified Observation Section (2.0)</td><td style="text-align: left;">2016‑11‑13 14:28:08</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.1.1</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Anatomic Pathology Structured Report (2.0)</td><td style="text-align: left;">2014‑05‑13 11:57:57</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.1</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Clinical Information Section (2.0)</td><td style="text-align: left;">2014‑05‑13 14:38:08</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.2</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Intraoperative Observation Section (2.0)</td><td style="text-align: left;">2014‑05‑13 19:29:16</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.3</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Macroscopic Observation Section (2.0)</td><td style="text-align: left;">2014‑05‑13 11:57:09</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.4</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Microscopic Observation Section (2.0)</td><td style="text-align: left;">2014‑05‑13 14:25:17</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.5</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Diagnostic Conclusion Section (2.0)</td><td style="text-align: left;">2014‑05‑13 19:31:26</td></tr><tr><th style="width: 20%; text-align: left;">Uses Template id</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.9.1</td><td style="text-align: left;">Include</td><td style="text-align: left;">[[File:Kyellow.png|16px]] X Specimen Identified</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.3.1.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|16px]] CDA Performer IHE (Body)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">2.16.840.1.113883.10.12.318</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|16px]] CDA Author (Body)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.6</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|16px]] CDA Informant(Header&amp;Body) APSR2 (2.0)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Additional participant in an entry APSR (Body)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">2.16.840.1.113883.10.12.324</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|16px]] CDA Reference</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Relationship</th><td style="text-align: left;" colspan="3">Adaptation: template 2.16.840.1.113883.10.12.303 (<i>2005‑09‑07</i>)</td></tr><tr class="explabel" style="vertical-align: top;"><td style="width: 20em; text-align: left;">Example</td><td colspan="3" class="explabelblue"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Example</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">observation</span> <span class="ppattribute">negationInd</span><span class="ppsign">="</span><span class="ppcontent">false</span><span class="ppsign">"</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">OBS</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.3.10.9.43</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.3.999</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">--example only--</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">derivationExpr</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">normal</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20170131163501</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">cs</span><span class="ppsign">"</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">methodCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">0001</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Complement fixation</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.5.84</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 0..* O --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">performer</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'CDA Performer IHE (Body)' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">performer</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">author</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">author</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">informant</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&amp;Body) APSR2' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">informant</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">participant</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">participant</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">reference</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">reference</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Card</th><th style="width: 2em; text-align: left;">Conf</th><th style="text-align: left;">Description</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:observation<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">OBS</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@moodCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@negationInd<br /></strong></tt></td></tr></table></td><td>bl</td><td><span><strong>0 … 1</strong></span></td><td> </td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.3.6.1.4.1.19376.1.3.10.9.43</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:code<br /></strong></tt></td></tr></table></td><td><strong>CE</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>shall be drawn from concept domain "any code for scoring items (children of  Microscopic specimen observable (observable entity)), e.g. 2.16.840.1.113883.1.11.16226 Breast tubule formation"</td></tr></table></td></tr><tr class="explabel" style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelblue"><div>Breast tubule formation</div><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">371470008</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.96</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:derivationExpr<br /></strong></tt></td></tr></table></td><td><strong>ST</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:text<br /></strong></tt></td></tr></table></td><td><strong>ED</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:statusCode<br /></strong></tt></td></tr></table></td><td><strong>CS</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 <i>ActStatus </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:effectiveTime<br /></strong></tt></td></tr></table></td><td><strong>IVL_TS</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:value<br /></strong></tt></td></tr></table></td><td><strong>INT</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td>Single coded numerical score item of a scoring system, e.g. 3 for Breast tubule formation (SCT)</td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@nullFlavor<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:methodCode<br /></strong></tt></td></tr></table></td><td><strong>CE</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14079 <i>ObservationMethod </i>(DYNAMIC)</td></tr><tr style="vertical-align: top;"><td>or</td></tr><tr style="vertical-align: top;"><td>@code shall be "MSRSCORE"</td></tr><tr style="vertical-align: top;"><td>@codeSystem shall be "2.16.840.1.113883.1.11.16226"</td></tr><tr style="vertical-align: top;"><td>@displayName shall be "measure scoring"</td></tr><tr style="vertical-align: top;"><td>@codeSystemName shall be "HL7 Observation type"</td></tr></table></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Included</td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td colspan="2"> from 1.3.6.1.4.1.19376.1.3.10.9.1 <i>X Specimen Identified</i> (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:specimen<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td><span style="color: rgb(51, 51, 51); font-family: Verdana, Arial, sans-serif; font-size: 12px; background-color: rgb(255, 234, 234);">Required when more than one specimen is documented at this level. </span>This is often the case in APSR.<br /></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SPC</td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td style="vertical-align: top; text-align: left;">[[File:Target.png|16px]]</td><td colspan="4" style="background-color: #F4FFF4;" class="tabtab">Associated with concepts:<table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span style="color: grey;">psr-data&#8203;element-</span>17</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Specimen / ">Specimen identification</td><td style="width: 35%; vertical-align: top;">APSR 2.0</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:specimenRole<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SPEC</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td>Specimen ID, coming from the LIS</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td style="vertical-align: top; text-align: left;">[[File:Target.png|16px]]</td><td colspan="4" style="background-color: #F4FFF4;" class="tabtab">Associated with concepts:<table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span style="color: grey;">psr-data&#8203;element-</span>68</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Specimen / Part / Block / Tissue section / ">Tissue section ID</td><td style="width: 35%; vertical-align: top;">APSR 2.0</td></tr><tr style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span style="color: grey;">psr-data&#8203;element-</span>98</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Specimen / Specimen identification / ">Specimen ID</td><td style="width: 35%; vertical-align: top;">APSR 2.0</td></tr><tr style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span style="color: grey;">psr-data&#8203;element-</span>66</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Specimen / Part / ">Part ID</td><td style="width: 35%; vertical-align: top;">APSR 2.0</td></tr><tr style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span style="color: grey;">psr-data&#8203;element-</span>67</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Specimen / Part / Block / ">Block ID</td><td style="width: 35%; vertical-align: top;">APSR 2.0</td></tr><tr style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span style="color: grey;">psr-data&#8203;element-</span>95</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Specimen / Specimen identification / ">Parent ID</td><td style="width: 35%; vertical-align: top;">APSR 2.0</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:performer<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td>Contains 1.3.6.1.4.1.19376.1.3.3.1.7 <i>CDA Performer IHE (Body)</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:author<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td>Contains 2.16.840.1.113883.10.12.318 <i>CDA Author (Body)</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:informant<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td>Contains 1.3.6.1.4.1.19376.1.8.1.4.6 <i>CDA Informant(Header&amp;Body) APSR2</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:participant<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td>Contains 1.3.6.1.4.1.19376.1.8.1.4.7 <i>Additional participant in an entry APSR (Body)</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:reference<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td>Contains 2.16.840.1.113883.10.12.324 <i>CDA Reference</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr></table></td></tr></table>
+
<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.9.43</td><th style="width: 20em; text-align: left;">Effective Date</th><td style="text-align: left;"> valid from 2016‑10‑11 10:26:17</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|16px]] Draft</td><th style="width: 20em; text-align: left;">Version Label</th><td style="text-align: left;">2.0</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">AssessmentScoringItemAPSR2.0</td><th style="width: 20em; text-align: left;">Display Name</th><td style="text-align: left;">Assessment Scoring Item APSR 2.0</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Description</th><td style="text-align: left;" colspan="3">Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF)<br /><br />Supportive Observation entry template for describing the granular Items for a scoring system, e.g.Elston-Ellis-Score or Gleason Score</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Context</th><td style="text-align: left;" colspan="3">Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.43</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Classification</th><td style="text-align: left;" colspan="3">CDA Entry Level Template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Open/Closed</th><td style="text-align: left;" colspan="3">Open (other than defined elements are allowed)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Used by / Uses</th><td style="text-align: left;" colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Used by 11 templates, Uses 6 templates</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Used by Template id</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.9.42</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Assessment Scoring System APSR 2.0 (2.0)</td><td style="text-align: left;">2016‑10‑10 11:33:36</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.4.4</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Assessment Scales Observation for Scoring Systems APSR2 (2.0)</td><td style="text-align: left;">2016‑10‑06 13:12:00</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.4.3</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] ICD-O-3 Typing and Grading Observation (2.0)</td><td style="text-align: left;">2015‑11‑29 17:03:18</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.3.6</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Problem Organizer (2.0)</td><td style="text-align: left;">2015‑08‑13 10:24:55</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.3.1</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Additional Specified Observation Section (2.0)</td><td style="text-align: left;">2016‑11‑13 14:28:08</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.1.1</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Anatomic Pathology Structured Report (2.0)</td><td style="text-align: left;">2014‑05‑13 11:57:57</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.1</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Clinical Information Section (2.0)</td><td style="text-align: left;">2014‑05‑13 14:38:08</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.2</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Intraoperative Observation Section (2.0)</td><td style="text-align: left;">2014‑05‑13 19:29:16</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.3</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Macroscopic Observation Section (2.0)</td><td style="text-align: left;">2014‑05‑13 11:57:09</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.4</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Microscopic Observation Section (2.0)</td><td style="text-align: left;">2014‑05‑13 14:25:17</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.5</td><td style="text-align: left;">[[File:Link.png|16px]]</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Diagnostic Conclusion Section (2.0)</td><td style="text-align: left;">2014‑05‑13 19:31:26</td></tr><tr><th style="width: 20%; text-align: left;">Uses Template id</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.9.1</td><td style="text-align: left;">Include</td><td style="text-align: left;">[[File:Kyellow.png|16px]] X Specimen Identified</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.3.1.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|16px]] CDA Performer IHE (Body)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">2.16.840.1.113883.10.12.318</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|16px]] CDA Author (Body)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.6</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|16px]] CDA Informant(Header&amp;Body) APSR2 (2.0)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|16px]] Additional participant in an entry APSR (Body)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">2.16.840.1.113883.10.12.324</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|16px]] CDA Reference</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Relationship</th><td style="text-align: left;" colspan="3">Adaptation: template 2.16.840.1.113883.10.12.303 (<i>2005‑09‑07</i>)</td></tr><tr class="explabel" style="vertical-align: top;"><td style="width: 20em; text-align: left;">Example</td><td colspan="3" class="explabelblue"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Example</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">observation</span> <span class="ppattribute">negationInd</span><span class="ppsign">="</span><span class="ppcontent">false</span><span class="ppsign">"</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">OBS</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.3.10.9.43</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.3.999</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">--example only--</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">derivationExpr</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">normal</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20170131163501</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">cs</span><span class="ppsign">"</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">methodCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">0001</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Complement fixation</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.5.84</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 0..* O --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">performer</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'CDA Performer IHE (Body)' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">performer</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">author</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">author</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">informant</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&amp;Body) APSR2' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">informant</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">participant</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">participant</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">reference</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">reference</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Card</th><th style="width: 2em; text-align: left;">Conf</th><th style="text-align: left;">Description</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:observation<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">OBS</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@moodCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@negationInd<br /></strong></tt></td></tr></table></td><td>bl</td><td><span><strong>0 … 1</strong></span></td><td> </td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.3.6.1.4.1.19376.1.3.10.9.43</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:code<br /></strong></tt></td></tr></table></td><td><strong>CE</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>shall be drawn from concept domain "any code for scoring items (children of  Microscopic specimen observable (observable entity)), e.g. 2.16.840.1.113883.1.11.16226 Breast tubule formation"</td></tr></table></td></tr><tr class="explabel" style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelblue"><div>Breast tubule formation</div><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">371470008</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.96</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:derivationExpr<br /></strong></tt></td></tr></table></td><td><strong>ST</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:text<br /></strong></tt></td></tr></table></td><td><strong>ED</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:statusCode<br /></strong></tt></td></tr></table></td><td><strong>CS</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 <i>ActStatus </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:effectiveTime<br /></strong></tt></td></tr></table></td><td><strong>IVL_TS</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:value<br /></strong></tt></td></tr></table></td><td><strong>INT</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td>Single coded numerical score item of a scoring system, e.g. 3 for Breast tubule formation (SCT)</td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@nullFlavor<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:methodCode<br /></strong></tt></td></tr></table></td><td><strong>CE</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14079 <i>ObservationMethod </i>(DYNAMIC)</td></tr><tr style="vertical-align: top;"><td>or</td></tr><tr style="vertical-align: top;"><td>@code shall be "MSRSCORE"</td></tr><tr style="vertical-align: top;"><td>@codeSystem shall be "2.16.840.1.113883.1.11.16226"</td></tr><tr style="vertical-align: top;"><td>@displayName shall be "measure scoring"</td></tr><tr style="vertical-align: top;"><td>@codeSystemName shall be "HL7 Observation type"</td></tr></table></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Included</td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td colspan="2"> from 1.3.6.1.4.1.19376.1.3.10.9.1 <i>X Specimen Identified</i> (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:specimen<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td>Required in XD-LAB when more than one specimen is documented at this level. Always required in APSR.<br /></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SPC</td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td style="vertical-align: top; text-align: left;">[[File:Target.png|16px]]</td><td colspan="4" style="background-color: #F4FFF4;" class="tabtab">Associated with concepts:<table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span style="color: grey;">psr-data&#8203;element-</span>17</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Specimen / ">Specimen identification</td><td style="width: 35%; vertical-align: top;">APSR 2.0</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:specimenRole<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SPEC</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td>Specimen ID, coming from the LIS</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td style="vertical-align: top; text-align: left;">[[File:Target.png|16px]]</td><td colspan="4" style="background-color: #F4FFF4;" class="tabtab">Associated with concepts:<table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span style="color: grey;">psr-data&#8203;element-</span>68</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Specimen / Part / Block / Tissue section / ">Tissue section ID</td><td style="width: 35%; vertical-align: top;">APSR 2.0</td></tr><tr style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span style="color: grey;">psr-data&#8203;element-</span>98</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Specimen / Specimen identification / ">Specimen ID</td><td style="width: 35%; vertical-align: top;">APSR 2.0</td></tr><tr style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span style="color: grey;">psr-data&#8203;element-</span>66</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Specimen / Part / ">Part ID</td><td style="width: 35%; vertical-align: top;">APSR 2.0</td></tr><tr style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span style="color: grey;">psr-data&#8203;element-</span>67</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Specimen / Part / Block / ">Block ID</td><td style="width: 35%; vertical-align: top;">APSR 2.0</td></tr><tr style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span style="color: grey;">psr-data&#8203;element-</span>95</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Specimen / Specimen identification / ">Parent ID</td><td style="width: 35%; vertical-align: top;">APSR 2.0</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:performer<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td>Contains 1.3.6.1.4.1.19376.1.3.3.1.7 <i>CDA Performer IHE (Body)</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:author<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td>Contains 2.16.840.1.113883.10.12.318 <i>CDA Author (Body)</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:informant<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td>Contains 1.3.6.1.4.1.19376.1.8.1.4.6 <i>CDA Informant(Header&amp;Body) APSR2</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:participant<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td>Contains 1.3.6.1.4.1.19376.1.8.1.4.7 <i>Additional participant in an entry APSR (Body)</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:reference<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td>Contains 2.16.840.1.113883.10.12.324 <i>CDA Reference</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(AssessmentScoringItemAPSR2.0)</span></td></tr></table></td></tr></table>

Version vom 7. Februar 2017, 03:40 Uhr

Id1.3.6.1.4.1.19376.1.3.10.9.43Effective Date valid from 2016‑10‑11 10:26:17
StatusKyellow.png DraftVersion Label2.0
NameAssessmentScoringItemAPSR2.0Display NameAssessment Scoring Item APSR 2.0
DescriptionTemplate CDA Observation (prototype, directly derived from POCD_RM000040 MIF)

Supportive Observation entry template for describing the granular Items for a scoring system, e.g.Elston-Ellis-Score or Gleason Score
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.43
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 11 templates, Uses 6 templates
Used by Template id as NameVersion
1.3.6.1.4.1.19376.1.3.10.9.42ContainmentKyellow.png Assessment Scoring System APSR 2.0 (2.0)2016‑10‑10 11:33:36
1.3.6.1.4.1.19376.1.3.10.4.4Link.pngKyellow.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 (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
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKyellow.png CDA Performer IHE (Body)DYNAMIC
2.16.840.1.113883.10.12.318ContainmentKgreen.png CDA Author (Body)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.7ContainmentKyellow.png Additional participant in an entry APSR (Body)DYNAMIC
2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA ReferenceDYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Example
Example
<observation negationInd="false" classCode="OBS" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.9.43"/>  <id root="1.2.3.999" extension="--example only--"/>  <code/>  <derivationExpr/>  <text/>  <statusCode code="normal"/>  <effectiveTime>
    <low value="20170131163501"/>  </effectiveTime>
  <value nullFlavor="cs" value="1"/>  <methodCode code="0001" displayName="Complement fixation" 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) 0..* O -->
  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'CDA Performer IHE (Body)' (dynamic) -->
  </performer>
  <author>
    <!-- template 2.16.840.1.113883.10.12.318 'CDA Author (Body)' (dynamic) -->
  </author>
  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (dynamic) -->
  </informant>
  <participant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (dynamic) -->
  </participant>
  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (dynamic) -->
  </reference>
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
(AssessmentScoringItemAPSR2.0)
Treetree.png@classCode
cs0 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1M(AssessmentScoringItemAPSR2.0)
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.9.43
Treetree.pnghl7:id
II1 … 1R(AssessmentScoringItemAPSR2.0)
Treetree.pnghl7:code
CE1 … 1R(AssessmentScoringItemAPSR2.0)
 CONF
shall be drawn from concept domain "any code for scoring items (children of Microscopic specimen observable (observable entity)), e.g. 2.16.840.1.113883.1.11.16226 Breast tubule formation"
 Example
Breast tubule formation
<code code="371470008" codeSystem="2.16.840.1.113883.6.96"/>
Treetree.pnghl7:derivationExpr
ST0 … 1(AssessmentScoringItemAPSR2.0)
Treetree.pnghl7:text
ED0 … 1R(AssessmentScoringItemAPSR2.0)
Treetree.pnghl7:statusCode
CS0 … 1(AssessmentScoringItemAPSR2.0)
 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 … 1(AssessmentScoringItemAPSR2.0)
Treetree.pnghl7:value
INT1 … 1RSingle coded numerical score item of a scoring system, e.g. 3 for Breast tubule formation (SCT)(AssessmentScoringItemAPSR2.0)
Treeblank.pngTreetree.png@nullFlavor
cs1 … 1R
Treetree.pnghl7:methodCode
CE0 … *(AssessmentScoringItemAPSR2.0)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (DYNAMIC)
or
@code shall be "MSRSCORE"
@codeSystem shall be "2.16.840.1.113883.1.11.16226"
@displayName shall be "measure scoring"
@codeSystemName shall be "HL7 Observation type"
Included0 … * from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC)
Treetree.pnghl7:specimen
0 … *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:performer
0 … *Contains 1.3.6.1.4.1.19376.1.3.3.1.7 CDA Performer IHE (Body) (DYNAMIC)(AssessmentScoringItemAPSR2.0)
Treetree.pnghl7:author
0 … *Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)(AssessmentScoringItemAPSR2.0)
Treetree.pnghl7:informant
0 … *Contains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (DYNAMIC)(AssessmentScoringItemAPSR2.0)
Treetree.pnghl7:participant
0 … *Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry APSR (Body) (DYNAMIC)(AssessmentScoringItemAPSR2.0)
Treetree.pnghl7:reference
0 … *Contains 2.16.840.1.113883.10.12.324 CDA Reference (DYNAMIC)(AssessmentScoringItemAPSR2.0)