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

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Version vom 1. April 2017, 03:13 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 5 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 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
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2008)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA authorDYNAMIC
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
RelationshipAdaptation: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Example
generated 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/>  <text/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20170224122203"/>  </effectiveTime>  <value nullFlavor="cs" value="1"/>  <interpretationCode code="A" displayName="abnormal" codeSystem="2.16.840.1.113883.5.83"/>  <referenceRange typeCode="REVF">
    <observationRange classCode="OBS" moodCode="EVN.CRT">
      <code code="" codeSystem="2.16.840.1.113883.5.4" displayName=""/>      <text/>      <effectiveTime value="20170224122203"/>      <value/>      <interpretation code="A" displayName="abnormal" codeSystem="2.16.840.1.113883.5.83"/>    </observationRange>  </referenceRange>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 0..* R -->
  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (dynamic) -->
  </performer>  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (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></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
CE CWE1 … 1R(AssessmentScoringItemAPSR2.0)
 CONF
shall be drawn from concept domain "<<395527009 | Microscopic specimen observable (observable entity) |"
 Example
for use case #1, Breast tubule formation
<code code="371470008" codeSystem="2.16.840.1.113883.6.96"/>
Treetree.pnghl7:text
ED0 … 1R(AssessmentScoringItemAPSR2.0)
Treetree.pnghl7:statusCode
CS0 … 1R(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 numerical score item of a scoring system, e.g. "2"  for Breast tubule formation(AssessmentScoringItemAPSR2.0)
Treeblank.pngTreetree.png@nullFlavor
cs1 … 1R
 Example
for use case #1
<value value="2"/>
Treetree.pnghl7:interpretationCode
CE CWE0 … 1R(AssessmentScoringItemAPSR2.0)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 Observation Interpretation (HL7) (DYNAMIC)
Treetree.pnghl7:referenceRange
0 … 1R(AssessmentScoringItemAPSR2.0)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREVF
Treeblank.pngTreetree.pnghl7:observationRange
0 … 1R(AssessmentScoringItemAPSR2.0)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FOBS
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 … 1FEVN.CRT
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CD CWE1 … 1R(AssessmentScoringItemAPSR2.0)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF1 … 1F2.16.840.1.113883.5.4 (Act Code)
Treeblank.pngTreeblank.pngTreetree.pnghl7:text
ED0 … 1R(AssessmentScoringItemAPSR2.0)
Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
TS0 … 1R(AssessmentScoringItemAPSR2.0)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
ANY1 … 1R(AssessmentScoringItemAPSR2.0)
Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretation
CD CWE0 … 1R(AssessmentScoringItemAPSR2.0)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 Observation Interpretation (HL7) (DYNAMIC)
Included0 … *R 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 Laboratory Performer (DYNAMIC)(AssessmentScoringItemAPSR2.0)
Treetree.pnghl7:author
0 … *Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author (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)
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