1.3.6.1.4.1.19376.1.8.1.1.1/static-2014-05-13T115757

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Id1.3.6.1.4.1.19376.1.8.1.1.1Effective Date valid from 2014‑05‑13 11:57:57
StatusKyellow.png DraftVersion Label2.0
NameAnatomicPathologyStructuredReportContentModuleDisplay NameAnatomic Pathology Structured Report Content Module
Description
Anatomic Pathology Structured Report Content Module. 

This document content module represents the generic set of constraints applied to any structured report for surgical pathology in all fields of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as for Cytopathology. 

The body of this Document Content Module specifies a common hierarchy of sections and entries depicted by figure 10.4.1-1 in Volume 1 IHE_PaLM_Suppl_APSR 2.0. The only mandatory section is the Diagnostic Conclusion Section. And the only mandatory entry is the Problem Organizer Entry below this section. 


ContextPathname /
LabelPaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 19 templates
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.1IncludeKgreen.png Human Patient (2017)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA author IHEDYNAMIC
2.16.840.1.113883.10.12.103IncludeKgreen.png CDA dataEntererDYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)DYNAMIC
2.16.840.1.113883.10.12.104IncludeKgreen.png CDA custodianDYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.4IncludeKgreen.png XD-LAB Information Recipient (2017)DYNAMIC
2.16.840.1.113883.10.12.106IncludeKgreen.png CDA legalAuthenticatorDYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.3IncludeKyellow.png CDA authenticator IHEDYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.6IncludeKgreen.png Ordering Provider (2017)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.1IncludeKyellow.png CDA Participant Specimen CollectorDYNAMIC
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)DYNAMIC
2.16.840.1.113883.10.12.113IncludeKgreen.png CDA componentOfDYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.1ContainmentKyellow.png Clinical Information Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.2ContainmentKyellow.png Intraoperative Observation Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.3ContainmentKyellow.png Macroscopic Observation Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.4ContainmentKyellow.png Microscopic Observation Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.3.10.3.1ContainmentKyellow.png Additional Specified Observation Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.5ContainmentKyellow.png Diagnostic Conclusion Section (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.2.6ContainmentKyellow.png Procedure Steps Section (2.0)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.1 (2005‑09‑07)
Example
example for use case #1
<ClinicalDocument xsi:schemaLocation="urn:hl7-org:v3 infrastructure/cda/CDA_extended.xsd">
  <realmCode code="UV"/>  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>  <templateId root="1.3.6.1.4.1.19376.1.8.1.1.1"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_1" assigningAuthorityName="IHE PaLM Technical Committee"/>  <code code="11526-1" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology Study"/>  <title>Anatomic Pathology Structured Report - Breast Biopsy</title>  <effectiveTime value="201001041605-0500"/>  <confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25"/>  <languageCode code="en-US"/>  <setId root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008" assigningAuthorityName="IHE PaLM Technical Committee"/>  <versionNumber value="1"/>  <!-- Patient -->
  <recordTarget>
    <patientRole>
      <id extension="0411886319605719371016" root="1.3.6.1.4.1.19376.1.8.9.2"/>      <addr use="HP">
        <streetAddressLine>39 East Street</streetAddressLine>        <postalCode>69499</postalCode>        <city>Appleton</city>        <state>WI</state>        <country>United States</country>      </addr>      <telecom nullFlavor="NASK"/>      <patient>
        <name>
          <prefix>Miss</prefix>          <given>EVE</given>          <family qualifier="BR">ONEWOMAN</family>        </name>        <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>        <birthTime value="19710921"/>      </patient>    </patientRole>  </recordTarget>  <!-- one or more author(s) of the report, with authoring time -->
  <author>
    <templateId root="1.3.6.1.4.1.19376.1.8.1.4.2"/>    <time value="20100104131933-0500"/>    <assignedAuthor>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>      <addr nullFlavor="MSK"/>      <telecom value="tel:+33-602030499"/>      <assignedPerson>
        <name>
          <given>Marcel</given>          <family>Pathologist</family>          <suffix>Ph D</suffix>        </name>      </assignedPerson>      <representedOrganization>
        <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>        <name>CANCER INSTITUTE</name>        <telecom nullFlavor="MSK"/>        <addr nullFlavor="MSK"/>      </representedOrganization>    </assignedAuthor>  </author>  <!-- one or more transcriptionists, with transcription time -->
  <dataEnterer>
    <time value="20100104131720-0500"/>    <assignedEntity>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="A32"/>      <addr nullFlavor="MSK"/>      <telecom nullFlavor="MSK"/>      <assignedPerson>
        <name>
          <given>Adeline</given>          <family>Medsecret</family>        </name>      </assignedPerson>    </assignedEntity>  </dataEnterer>  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Body) APSR2' (dynamic), not used in use case #1 -->
  </informant>  <!-- The unique custodian of this document is the sending pathology lab that will administer it (further updates, deprecation) -->
  <custodian>
    <assignedCustodian>
      <representedCustodianOrganization>
        <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>        <name>CANCER INSTITUTE</name>        <telecom use="PUB" value="0466666666"/>        <addr>
          <streetAddressLine>38 Cramberry Street</streetAddressLine>          <postalCode>69499</postalCode>          <city>Appleton</city>          <state>WI</state>        </addr>      </representedCustodianOrganization>    </assignedCustodian>  </custodian>  <!-- One or more additional intended recipients (other than the ordering physician) -->
  <informationRecipient>
    <templateId root="1.3.6.1.4.1.19376.1.3.3.1.4"/>    <intendedRecipient>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="987"/>      <addr>
        <streetAddressLine>1600 Clifton Road</streetAddressLine>        <city>Atlanta</city>        <state>GA</state>        <postalCode>30333</postalCode>      </addr>      <telecom value="tel:404-639-3535"/>      <informationRecipient>
        <name>
          <family>WOULDLIKETOKNOW</family>          <given>Thomas</given>        </name>      </informationRecipient>    </intendedRecipient>  </informationRecipient>  <!-- The unique legal authenticator: The person assuming the final responsibility of the report and signing it -->
  <legalAuthenticator>
    <time value="20100104152503-0500"/>    <signatureCode code="S"/>    <assignedEntity>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>      <assignedPerson>
        <name>
          <given>Marcel</given>          <family>Pathologist</family>        </name>      </assignedPerson>    </assignedEntity>  </legalAuthenticator>  <!-- Zero or more additional content validator(s): pathologists having validated some part of the report -->
  <authenticator>
    <templateId root="1.3.6.1.4.1.19376.1.8.1.4.3"/>    <time value="20100104142503-0500"/>    <signatureCode code="S"/>    <assignedEntity>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567898"/>      <addr nullFlavor="MSK"/>      <telecom nullFlavor="MSK"/>      <assignedPerson>
        <name>
          <given>Jonas</given>          <family>Jones</family>          <prefix>MD</prefix>        </name>      </assignedPerson>    </assignedEntity>  </authenticator>  <!-- The ordering physician -->
  <participant typeCode="REF">
    <templateId root="1.3.6.1.4.1.19376.1.3.3.1.6"/>    <time>
      <high value="20091231"/>    </time>    <associatedEntity classCode="PROV">
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567892"/>      <addr nullFlavor="NASK"/>      <telecom value="tel:0147150000" use="EC"/>      <associatedPerson>
        <name>
          <prefix>Doctor</prefix>          <given>Eva</given>          <family>Surgeon</family>          <suffix>Ph D</suffix>        </name>      </associatedPerson>    </associatedEntity>  </participant>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.1 'CDA participant specimen collector' (dynamic) 0..* R, not used in use case #1 -->
  <!-- Identification of the order, extension is Order-ID -->
  <inFulfillmentOf>
    <order>
      <id root="1.3.6.1.4.1.19376.1.8.9.8" extension="12345"/>    </order>  </inFulfillmentOf>  <!-- Documented act(s): The pathology examination procedure, extension is Accession number -->
  <documentationOf>
    <serviceEvent>
      <id root="1.3.6.1.4.1.19376.1.8.9.9" extension="A7102400008"/>      <code code="371528001" displayName="Pathology report (record artifact)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>      <lab:statusCode code="completed"/>      <effectiveTime>
        <!-- Start: Date&time of reception of this order and the attached specimens -->
        <low value="200912300922-0500"/>        <!-- End -->
        <high value="201001041605-0500"/>      </effectiveTime>      <!-- Performing laboratory -->
      <performer typeCode="PRF">
        <templateId root="1.3.6.1.4.1.19376.1.3.3.1.7"/>        <time>
          <high value="201001041605-0500"/>        </time>        <assignedEntity>
          <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>          <representedOrganization>
            <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>            <name>CANCER INSTITUTE</name>            <telecom nullFlavor="MSK"/>            <addr nullFlavor="MSK"/>          </representedOrganization>        </assignedEntity>      </performer>    </serviceEvent>  </documentationOf>  <!-- include template 1.3.6.1.4.1.19376.1.3.1.9999.10.9.16 'RelatedDocument Parent Document' (dynamic) 0..1 R, not used in use case #1 -->
  <!-- Patient encounter: The patient stay in the hospital where the surgery was performed -->
  <componentOf>
    <encompassingEncounter>
      <id root="1.3.6.1.4.1.19376.1.8.9.7" extension="234567890"/>      <code code="ACUTE" displayName="inpatient acute"/>      <effectiveTime>
        <high value="2201001040735-0500"/>      </effectiveTime>      <location typeCode="LOC">
        <healthCareFacility classCode="SDLOC">
          <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="11223344"/>          <serviceProviderOrganization classCode="ORG" determinerCode="INSTANCE">
            <name>Surgery theater</name>            <asOrganizationPartOf>
              <wholeOrganization>
                <name>CANCER INSTITUTE</name>              </wholeOrganization>            </asOrganizationPartOf>          </serviceProviderOrganization>        </healthCareFacility>      </location>    </encompassingEncounter>  </componentOf>  <!-- Structured body -->
  <component typeCode="COMP" contextConductionInd="true">
    <structuredBody classCode="DOCBODY" moodCode="EVN">
      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.1 'Clinical Information Section' (dynamic) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.2 'Intraoperative Observation Section' (dynamic) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.3 'Macroscopic Observation Section' (dynamic) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.4 'Microscopic Observation Section' (dynamic) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.3.10.3.1 'Additionally Specified Observation Section' (dynamic) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.5 'Diagnostic Conclusion Section' (dynamic) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.6 'Procedure Steps Section' (dynamic) -->
      </component>    </structuredBody>  </component></ClinicalDocument>
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
1 … 1MPaLM…dule
Treetree.png@classCode
cs1 … 1FDOCCLIN
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1MThis element is identifying the set of constraints applied to the CDA R2 standard by this IHE specification of a AP report. The following templateId SHALL be present and valued as follows to indicate compliance with the APSR 2.0 content module specification.
PaLM…dule
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.1.1
Treetree.pnghl7:realmCode
CS CWE1 … 1MThis element SHALL be present and is valued from the RealmOfUse [2.16.840.1.113883.1.11.11050] subset, within the VocabularyDomainQualifier value set. In the international context of this profile used as it is without any further extension, the realm code SHALL be <realmCode code="UV"/> (universal).

Whenever a national extension has been defined and is used, the realm code SHALL identify this national extension.

PaLM…dule
Treetree.pnghl7:typeId
II1 … 1MThis element is a technology-neutral explicit reference to the standard CDA R2. It SHALL be present and valued as follows:
ClinicalDocument/typeId@root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models);
ClinicalDocument.typeId@extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description).
PaLM…dule
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.1.3
Treeblank.pngTreetree.png@extension
st1 … 1FPOCD_HD000040
Treetree.pnghl7:id
II1 … 1MClinicalDocument/Id SHALL be present. It represents the unique instance identifier of the clinical document. The combination of the root and extension attributes SHALL provide a globally unique identifier, in accordance with CDA R2, without further constraints.

PaLM…dule
Treeblank.pngTreetree.png@root
uid1 … 1RHere the OID for PAT exemplary instances, in practice the OID of the LIS
Treeblank.pngTreetree.png@extension
st1 … 1RHere a hypothetical document ID, most often derived from the accession number
 ConstraintA report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report.
The unique id of the current revision of the report is carried by the id element, and is composed of 
  • id@root, which SHALL be an OID,
  • and optionally id@extension, which can be any string so that the concatenation of the two attributes root and extension provide a globally unique id, which identifies this release of the report. 
 Example
Report ID from use case #1
<id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_1" assigningAuthorityName="IHE PaLM Technical Committee"/>
Treetree.pnghl7:code
CE CNE1 … 1MClinicalDocument/code SHALL be present. The document type of this content module is always
<code code="11526-1"
codeSystem="2.16.840.1.113883.6.1"
displayName="Pathology Study"
codeSystemName="LOINC"/>


PaLM…dule
Treeblank.pngTreetree.png@code
CONF1 … 1F11526-1
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1FPathology Study
Treetree.pnghl7:title
ST1 … 1MThe APSR <title> SHALL be present. It is the local translation of the code@displayName.

PaLM…dule
 CONF
element content shall be "Anatomic Pathology Structured Report"
 Example
Report title from use case #1
<title>ANATOMIC PATHOLOGY REPORT - BREAST BIOPSY</title>
Treetree.pnghl7:effectiveTime
TS1 … 1MClinicalDocument/effectiveTime SHALL be present. It contains the creation date & time of the laboratory report as an electronic document. In case this is a new revision replacing a previous version (identified in parentDocument), this is the date & time of the new revision.

PaLM…dule
Treetree.pnghl7:confidentialityCode
CE CNE1 … 1MClinicalDocument/confidentialityCode SHALL be present in accordance with the HL7 CDA R2 standard.
PaLM…dule
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)
Treetree.pnghl7:language​Code
CS CNE1 … 1MClinicalDocument/languageCode SHALL be present in accordance with the HL7 CDA R2 standard.
PaLM…dule
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
Treetree.pnghl7:setId
II1 … 1MClinicalDocument/setId SHALL be present to enable further updates of the clinical document. It is an identifier that is common across all revisions of this AP report.
PaLM…dule
Treeblank.pngTreetree.png@root
uid1 … 1R
Treeblank.pngTreetree.png@extension
st1 … 1R
 ConstraintA report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report.
The setId element provides a globally unique identifier that is common across all successive revisions of the report. This identifier is similarly composed of setId@root, which SHALL be an OID, and optionally setId@extension. 
 Example
Report set ID from use case #1
<id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008" assigningAuthorityName="IHE PaLM Technical Committee"/>
Treetree.pnghl7:versionNumber
INT0 … 1RClinicalDocument/versionNumber MAY be present. As requested by the CDA standard, it is an integer value used as versioning.

PaLM…dule
Treeblank.pngTreetree.png@value
int1 … 1R
 ConstraintA report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report.
The version number of the current revision of the report is a positive integer (1, 2 …) provided in the versionNumber element.
 Example
Report version number for use case #1
<versionNumber value="1"/>
Included1 … 1M from 1.3.6.1.4.1.19376.1.3.3.1.1 Human Patient (DYNAMIC)
The Patient.

The anatomic pathology report is related to ONE SINGLE patient. 
  • A patient SHALL be identified with at least one unique patientRole/Id.  
  • The patient address and telecom SHALL be provided (or null flavored).  
  • The patient identity SHALL provide AT LEASTthe patient full name, sex and date/time of birth. 
    Treetree.pnghl7:recordTarget
    		1 … 1MPaLM…dule
    Treeblank.pngTreetree.pnghl7:patientRole
    		1 … 1RPaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *RPaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.PaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL1 … *All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.PaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:patient
    		1 … 1PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … 1PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		PN1 … *PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:administrative​Gender​Code
    		CE1 … 1RPaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:birthTime
    		TS1 … 1RPaLM…dule
    Included1 … *M from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (DYNAMIC)
    The Author Content Module represents an author of the report. This element is repeatable. The sub-element  author/time  carries the date/time of the authoring action. 

    At least one ClinicalDocument/author SHALL be present with a time in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. The author/time element carries the date&time the AP report was produced. The AP report can be authored by a software system or by a person or by both.

    Source: PaLM Suppl.APSR 2.0‑3: 6.3.6.2
    Treetree.pnghl7:author
    		1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FAUT
     Example
    author is a person
    <author typeCode="AUT" contextControlCode="OP">
      <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
        <!-- ... -->
      </assignedAuthor>    </author>
    Treeblank.pngTreetree.pnghl7:templateId
    		1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
    Treeblank.pngTreetree.pnghl7:time
    		TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.pnghl7:assignedAuthor
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FASSIGNED
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Choice1 … 1
    The author is either an assigned person or an authoring device.
    Elements to choose from:
    • hl7:assigned​Person
    • hl7:assigned​Authoring​Device
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Included0 … * from 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)
    The name(s) SHALL be given.
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPSN
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FDEV
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		cs0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
     Example
    represented organization for author as a device
    <representedOrganization classCode="ORG" determinerCode="INSTANCE">
      <name>
        <!-- ... -->
      </name>    </representedOrganization>
    Included0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)
    The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given.
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
    		CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPART
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		CONF1 … 1F2.16.840.1.113883.5.111
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
    		CS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
     CONF
    The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    		IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
    		CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Included0 … *R from 2.16.840.1.113883.10.12.103 CDA dataEnterer (DYNAMIC)
    Transcriptionist
    Treetree.pnghl7:dataEnterer
    		0 … *RPaLM…dule
    Treeblank.pngTreetree.png@typeCode
    		0 … 1FENT
    Treeblank.pngTreetree.png@context​Control​Code
    		0 … 1FOP
    Treeblank.pngTreetree.pnghl7:time
    		TS0 … 1PaLM…dule
    Treeblank.pngTreetree.pnghl7:assignedEntity
    		1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)PaLM…dule
    Treetree.pnghl7:informant
    		0 … *RZero or more informant MAY be mentioned in the header of the report. An informant is either an  assignedEntity  (a professional participating to the healthcare process, and who was assigned a defined role in that process) or a  relatedEntity  (a person who knows the patient and has provided relevant information concerning the patient). Hence the condition is either  assignedEntity  is present or  relatedEntity  is present. These two elements are defined in the content module “Informant”.

    Source: PaLM Suppl. APSR 2.0-3: 6.3.6.5

    Contains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (DYNAMIC)    		PaLM…dule
    Included1 … 1M from 2.16.840.1.113883.10.12.104 CDA custodian (DYNAMIC)
    ClinicalDocument/custodian SHALL be present with an id in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. It represents the organization that is in charge of maintaining the AP report.
    Treetree.pnghl7:custodian
    		1 … 1MPaLM…dule
    Treeblank.pngTreetree.png@typeCode
    		0 … 1FCST
    Treeblank.pngTreetree.pnghl7:assignedCustodian
    		1 … 1PaLM…dule
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FASSIGNED
    Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Custodian​Organization
    		1 … 1PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *MPaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … 1PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … 1PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … 1PaLM…dule
    Included0 … *R from 1.3.6.1.4.1.19376.1.3.3.1.4 XD-LAB Information Recipient (DYNAMIC)
    The Intended Recipient Content Module represents a healthcare provider,  other than the ordering physician, expecting to receive a copy of the report. This repeatable element informationRecipient of the CDA header is used to list the intended recipients who were known at the time the report was created and issued. 


    Source: PaLM TF-3: 6.3.2.14
    Treetree.pnghl7:information​Recipient
    		0 … *RPaLM…dule
    Treeblank.pngTreetree.pnghl7:templateId
    		II1 … 1MPaLM…dule
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.3.3.1.4
    Treeblank.pngTreetree.pnghl7:intended​Recipient
    		1 … 1RPaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *RPaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *PaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL1 … *PaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:information​Recipient
    		0 … 1Contains 1.3.6.1.4.1.19376.1.3.10.9.18 PlayingEntity or person with Name (DYNAMIC)PaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:received​Organization
    		0 … 1Contains 1.3.6.1.4.1.19376.1.3.10.9.13 Organization with Name, Addr, Telecom (DYNAMIC)PaLM…dule
    Included1 … 1M from 2.16.840.1.113883.10.12.106 CDA legalAuthenticator (DYNAMIC)
    The Legal authenticator Content Module describes a pathologist having verified the content of the report, using the element legalAuthenticator.

    The report SHALL have one legal Authenticator


    Source: PaLM TF-3: 6.3.2.15

    Treetree.pnghl7:legalAuthenticator
    		1 … 1MPaLM…dule
    Treeblank.pngTreetree.png@typeCode
    		0 … 1FLA
    Treeblank.pngTreetree.png@context​Control​Code
    		0 … 1FOP
    Treeblank.pngTreetree.pnghl7:time
    		TS1 … 1RPaLM…dule
    Treeblank.pngTreetree.pnghl7:signatureCode
    		CS1 … 1RPaLM…dule
     CONF
    The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)
    Treeblank.pngTreetree.pnghl7:assignedEntity
    		1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)PaLM…dule
    Included0 … *R from 1.3.6.1.4.1.19376.1.8.1.4.3 CDA authenticator IHE (DYNAMIC)

    The Content validator Content Module describes a pathologist having verified the content of the report, using the element authenticator. This element authenticator is used when the pathologist having verified the content of the report is distinct from the pathologist assuming the legal responsibility for this report, described in the legalAuthenticator element.

    The report MAY have zero or more Content Validators.


    Source: PaLM Suppl. APSR 2.0-3: 6.3.6.3
    Treetree.pnghl7:authenticator
    		0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FAUTHEN
    Treeblank.pngTreetree.pnghl7:templateId
    		1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.3
    Treeblank.pngTreetree.pnghl7:time
    		TS1 … 1RTime of validationPaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator
    Treeblank.pngTreetree.pnghl7:assignedEntity
    		0 … 1CAssignedPerson SHALL be given with name, representedOrganization MAY be given.
    Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)    		PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator
    Included1 … 1R from 1.3.6.1.4.1.19376.1.3.3.1.6 Ordering Provider (DYNAMIC)
    The Ordering Provider Content Module represents the physician who has submitted the specimen examination order to the anatomic pathology laboratory. As specified in PaLM TF-3, this physician is represented in the CDA header as a participant element with the typeCode attribute valued “REF”. The sub-element participant/time carries the date/time of issuance of the order.

    Source: PaLM TF-3: 6.3.2.17
    Treetree.pnghl7:participant
    		1 … 1RReferral Ordering PhysicianPaLM…dule
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FREF
    Treeblank.pngTreetree.pnghl7:templateId
    		II1 … 1PaLM…dule
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.3.3.1.6
    Treeblank.pngTreetree.pnghl7:time
    		IVL_TS1 … 1RThis element represents the date and time the order was placed. Time MAY be present.PaLM…dule
    Treeblank.pngTreetree.pnghl7:associated​Entity
    		1 … 1PaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *RThe address of this person (referral ordering physician) SHALL be present.PaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL.AT1 … *RThe telecom of this person (referral ordering physician) SHALL be present.PaLM…dule
     Schematron assertroleKred.png error 
     testnot(hl7:assigned​Person) or hl7:assigned​Person/hl7:name 
     MessageThe <name> sub-element SHALL be present when <assignedPerson> present. 
    Treeblank.pngTreeblank.pngTreetree.pnghl7:associated​Person
    		0 … 1RPaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:scoping​Organization
    		0 … 1PaLM…dule
    Included0 … *R from 1.3.6.1.4.1.19376.1.8.1.4.1 CDA Participant Specimen Collector (DYNAMIC)
    The Specimen Collector Content Module is only used in case a specimen provided as input to the AP act documented in this report, was collected by a different party than the ordering physician. In that case, this specimen collector is represented in the CDA header as a participant element with the typeCode attribute valued “DIST” and the sub-element participant/time carries the time period of the specimen collection.

    Source: PAT TF-3: 6.2.6.1


    Treetree.pnghl7:participant
    		0 … *RThe Specimen Collector Content Module is only used in case a specimen provided as input to the AP act documented in this report, was collected by a different party than the ordering physician. In that case, this specimen collector is represented in the CDA header as a participant element with the typeCode attribute valued “DIST” and the sub-element participant/time carries the time period of the specimen collection.
    		PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FDIST
    Treeblank.pngTreetree.pnghl7:templateID
    		II1 … 1MPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.1
    Treeblank.pngTreetree.pnghl7:time
    		IVL_TS1 … 1MSpecimen collection time

    The specimen collection time is an interval, which may be reduced to a point in time (see usage of data type IVL_TS).

    		PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreetree.pnghl7:associated​Entity
    		0 … 1RAt least one of the two elements associatedPerson and scopingOrganization must be present. Both may be present. 

    		PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs1 … 1FPROV
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL.AT1 … *RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.pnghl7:associated​Person
    		0 … *CPerson who collected the specimen.
    Only full name(s) SHALL be given.
    Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)    		PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.pnghl7:scoping​Organization
    		0 … 1COrganization taking care for specimen collection.
    Identifiers, name, telecom, and address SHOULD be given.
    Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)    		PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
    Treetree.pnghl7:inFulfillmentOf
    		0 … 1RThe inFulfillmentOf/order element MAY be present. It represents the Placer Order or the Placer Group that was fulfilled, the Id of which is carried by inFulfillmentOf/order/id.
    		PaLM…dule
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FFLFS
    Treeblank.pngTreetree.pnghl7:order
    		1 … 1MPaLM…dule
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs1 … 1FACT
    Treeblank.pngTreeblank.pngTreetree.png@moodCode
    		cs1 … 1FRQO
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *RPlacer order group ID or Placer order ID
    		PaLM…dule
    Treetree.pnghl7:documentationOf
    		1 … 1MDocumented act.PaLM…dule
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FDOC
    Treeblank.pngTreetree.pnghl7:serviceEvent
    		1 … 1MThe AP report is documenting a service (documentationOf/serviceEvent) performed by a surgical pathology laboratory. The Laboratory Performer Content Module represents this laboratory, and is fully described in the sub-element documentationOf/serviceEvent/performer.
    In case more than one laboratory contributed to a service, only the primary laboratory is in the CDA header, attached to the serviceEvent element, and the other (secondary) laboratories are described only in the sections of the report that they contributed to, in the body of the report.


    Source: PaLM TF3: 6.3.2.19

    		PaLM…dule
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs1 … 1R
    Treeblank.pngTreeblank.pngTreetree.png@moodCode
    		cs1 … 1R
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *MID of the Act, i.e. Accession numberPaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE CWE0 … 1RPaLM…dule
     CONF
    @code shall be "PATREPE"
    @codeSystem shall be "2.16.840.1.113883.5.4"
    @codeSystemName shall be "HL7 ActCode"
    @displayName shall be "pathology report entry task"
    or
    @code shall be "371528001"
    @codeSystem shall be "2.16.840.1.113883.6.96"
    @codeSystemName shall be "SCT"
    @displayName shall be "Pathology report (record artifact)"
    Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    		IVL_TS0 … 1RUse of sub element documentationOf/serviceEvent/effectiveTime to document the time boundaries of events in the document is appropriate.
    		PaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pngihe-lab:statusCode
    		CS CNE0 … 1R

    This APSR Content Module can express both final and non-final reports. To distinguish between the two, the statusCode element has been added to the documentationOf/serviceEvent element. A non-final report is a report documenting a serviceEvent, which is in the status "active". This sub-element serviceEvent/statusCode is optional. When it is not present the serviceEvent is assumed to be in the status "completed".
    The statusCode below documentationOf/serviceEvent is an extension to the CDA R2 standard, added by PaLM TF-3 to distinguish a preliminary report (statusCode@code="active") from a final report (statusCode@code="completed"). 
    The statusCode sub element is  further described in section A.3 of PaLM TF-3. This sub-element is required. When it is not there, the documented Act is assumed to be completed and the report is assumed to be a final report.


    This extension to the standard is protected by a dedicated namespace associated in the ClinicalDocument element to the prefix lab:

    <Clinical Document  xmlns:lab="urn:oid:1.3.6.1.4.1.19376.1.3.2" … > 

    Source: PaLM TF3: 6.3.2.19

    		PaLM…dule
     ConstraintThe statusCode@code="completed" is only applicable, if ALL content modules of the Clinical Document have the statusCode@code="completed", too, or have the statusCode@code="aborted".
     CONF
    The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.4 ActStatusActiveCompleted (DYNAMIC)
     Schematron assertroleKred.png error 
     testhl7:serviceEvent/ihe-lab:statusCode[@code='completed'] 
     MessageStatus code of all Content Modules SHALL be "complete" or "aborted" 
    Treeblank.pngTreeblank.pngTreetree.pnghl7:performer
    		0 … *RContains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC)PaLM…dule
    Treetree.pnghl7:relatedDocument
    		0 … 1R

    ClinicalDocument/relatedDocument/parentDocument

    This element SHALL be present in case of an update replacement of a previous report. In this case relatedDocument@typeCode attribute SHALL be valued "RPLC", the new report replacing the parent one.

    Note 1: A non-final laboratory report published in an XDS infrastructure will likely be replaced afterwards by the final report. When this event occurs, the Content Creator Actor SHALL apply the following rules:

    • ClinicalDocument/setId SHALL have the same value in the new report as in the replaced report.
    • ClinicalDocument/versionNumber SHALL be incremented in the replacing report (i.e., the final one).
    • ClinicalDocument/relatedDocument@typeCode attribute SHALL be valued ”RPLC”
    • ClinicalDocument/relatedDocument/parentDocument/id in the new report SHALL be equal to ClinicalDocument/ id of the replaced document.

    The Document Source Actor SHALL apply the following rules on XDSDocumentEntry metadata:

    • The final report SHALL be associated with the previously published one, using RPLC relationship and the previous report SHALL be “Deprecated” as described in ITI TF-2:4.1.6.1.

    Note 2: A non-final report can also be replaced by a more recent, albeit still non-final report. The rules above also apply in this case.

    Note 3: A final report can also be replaced by a corrective final report. The rules above also apply in this case.

    		PaLM…dule
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FRPLC
     relatedDocument@typeCode attribute SHALL be valued "RPLC"
    Treeblank.pngTreetree.pnghl7:parentDocument
    		ANY1 … 1MPaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … 1MSHALL be equal to ClinicalDocument/ id of the replaced document.
    		PaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:setId
    		II1 … 1MSHALL have the same value in the new report as in the replaced report.
    		PaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:versionNumber
    		INT0 … 1RSHALL have the same value as in the replaced report (when provided there).
    		PaLM…dule
    Included0 … 1R from 2.16.840.1.113883.10.12.113 CDA componentOf (DYNAMIC)
    The ClinicalDocument/componentOf/encompassingEncounter element MAY be present.

    It describes the encounter during which the reported AP observations were ordered. When present the encounter SHALL:

    • be identified with an id element: encompassingEncounter/id
    • The encounter SHALL have an effective time that represents the time interval (possibly still running, e.g., an inpatient current stay) of the encounter or a point in time at which the encounter took place (e.g., an outpatient consultation): encompassingEncounter/ effectiveTime

    The encounter MAY provide any number of encounter participants (encompassingEncounter/encounterParticipant/assignedEntity). When present, encounter participants SHALL be in accordance with the HL7 CDA R2 standard with a time and further constrained by this specification to require the presence of name, addr and telecom. Additionally, the encounter participant SHALL have a typeCode with one the values selected from the x_EncounterParticipant domain: The encounter MAY precise the patient location during this encounter. This is the healthcare facility in which the patient was located when the reported AP observations were ordered: encompassingEncounter/location/healthCareFacility. This healthcare facility can be represented as a physical place (e.g., room, floor, building, office) or as an organization (e.g., service, department, team) or both: healthCareFacility/location, healthCareFacility/serviceProviderOrganization.

    Treetree.pnghl7:componentOf
    		0 … 1RPaLM…dule
    Treeblank.pngTreetree.png@typeCode
    		0 … 1FCOMP
    Treeblank.pngTreetree.pnghl7:encompassing​Encounter
    		1 … 1PaLM…dule
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FENC
    Treeblank.pngTreeblank.pngTreetree.png@moodCode
    		0 … 1FEVN
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *PaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1PaLM…dule
     CONF
    The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC)
    Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    		IVL_TS1 … 1RPaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:discharge​Disposition​Code
    		CE0 … 1PaLM…dule
     CONF
    shall be drawn from concept domain "EncounterDischargeDisposition"
    Treeblank.pngTreeblank.pngTreetree.pnghl7:responsible​Party
    		0 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		0 … 1FRESP
    Treeblank.pngTreeblank.pngTreetree.pnghl7:encounterParticipant
    		0 … *PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs1 … 1R
     CONF
    The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:time
    		IVL_TS0 … 1PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assignedEntity
    		1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)PaLM…dule
    Treeblank.pngTreeblank.pngTreetree.pnghl7:location
    		0 … 1PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		0 … 1FLOC
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:health​Care​Facility
    		1 … 1PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FSDLOC
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1PaLM…dule
     CONF
    The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:location
    		0 … 1Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC)PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:service​Provider​Organization
    		0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)PaLM…dule
    Treetree.pnghl7:component
    		1 … 1RBody of the CDA Clinical documentPaLM…dule
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl1 … 1Ftrue
    Treeblank.pngTreetree.pnghl7:structuredBody
    		1 … 1RPaLM…dule
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs1 … 1FDOCBODY
    Treeblank.pngTreeblank.pngTreetree.png@moodCode
    		cs1 … 1FEVN
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    		0 … 1RThe Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, clinical laboratory data, specimen(s) description, collection procedure, reason for anatomic pathology procedure.
    Contains 1.3.6.1.4.1.19376.1.8.1.2.1 Clinical Information Section (DYNAMIC)    		PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code='22636-5' and @codeSystem='2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    		bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    		0 … 1R

    The Intraoperative Observation section contains an intraoperative diagnosis for each specimen examined, the specimen identification and description, intraoperative observation procedure description (frozen section, gross examination, intraoperative cytology) and derived specimen dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, and electron microscopy).


    Contains 1.3.6.1.4.1.19376.1.8.1.2.2 Intraoperative Observation Section (DYNAMIC)    		PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code='83321-0' and @codeSystem='2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    		bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    		0 … 1RThe Macroscopic Observation section contains the description of the specimen received or obtained by the laboratory (specimen type and state), the gross observation, links to gross images, if taken, processing information and tissue disposition (representative sampling and tissue submitted for additional studies or sent to biorepository.
    Contains 1.3.6.1.4.1.19376.1.8.1.2.3 Macroscopic Observation Section (DYNAMIC)    		PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code='22634-0' and @codeSystem='2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    		bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    		0 … 1R

    The Microscopic Observation section contains optionally the histopathologic findings of the case and many laboratories use this section to record the results of histochemical and immunohistochemical stains.


    Contains 1.3.6.1.4.1.19376.1.8.1.2.4 Microscopic Observation Section (DYNAMIC)    		PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code='22635-7' and @codeSystem='2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    		bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    		0 … 1R

    The Additional Specific Observation section includes additional pathologic finding(s) and the results of ancillary study(ies) with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken. 


    Contains 1.3.6.1.4.1.19376.1.3.10.3.1 Additional Specified Observation Section (DYNAMIC)    		PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code='xxxxx-x' and @codeSystem='2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    		bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    		1 … 1M

    The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.


    Contains 1.3.6.1.4.1.19376.1.8.1.2.5 Diagnostic Conclusion Section (DYNAMIC)    		PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code='22637-3' and @codeSystem='2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    		bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    		0 … 1R

    The Procedure steps section contains the description of tissue dissection: representative specimens and derived specimens dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, electron microscopy, etc.) or biorepository.


    Contains 1.3.6.1.4.1.19376.1.8.1.2.6 Procedure Steps Section (DYNAMIC)    		PaLM…dule
    Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code='46059-2' and @codeSystem='2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    		bl1 … 1Ftrue
    Abgerufen von „https://wiki.hl7.de/index.php?title=1.3.6.1.4.1.19376.1.8.1.1.1/static-2014-05-13T115757&oldid=44157“