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=Template ''MacroscopySection''=
 
=Template ''MacroscopySection''=
 
==Description==
 
==Description==
<p>The Macroscopic Observation section contains the description of the specimen(s) 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.
+
<p>The Macroscopic Observation section contains the description of the specimen(s) 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.</p>
</p>
 
 
==Actual version==
 
==Actual version==
 
{{:{{BASEPAGENAME}}/dynamic}}
 
{{:{{BASEPAGENAME}}/dynamic}}

Version vom 9. März 2017, 03:42 Uhr

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Template MacroscopySection

Description

The Macroscopic Observation section contains the description of the specimen(s) 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.

Actual version

Id1.3.6.1.4.1.19376.1.8.1.2.3Effective Date valid from 2014‑05‑13 11:57:09
StatusKyellow.png DraftVersion Label2.0
NameMacroscopySectionDisplay NameMacroscopic Observation Section
Description
The Macroscopic Observation section contains the description of the specimen(s) 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.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.3
LabelPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 2 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.1.1ContainmentKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example
Example
<section>
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  <entry typeCode="COMP">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->
  </entry>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … 1RPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
 Constraint

   This section SHALL contain a code element populated with these attributes:
   

@code ="22634-0"

@codeSystem ="2.16.840.1.113883.6.1"

@displayName ="Pathology report gross observation" 

This section does not contain any subsection. The section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.

The section SHOULD contain as many Problem Organizer entry elements as there are problems or groups thereof to be described. These entries provide the machine-readable data corresponding to the narrative block.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

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Treetree.pnghl7:code
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1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1FPathology report gross observation
Treetree.pnghl7:title
ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
 CONF
element content shall be "MACROSCOPIC OBSERVATION SECTION"
 Example<title>Macroscopic Observation</title>
Treetree.pnghl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
 Example
example for use case #1
<text>A. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)</text>
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
Author


Source: PaLM Suppl. APSR 2.0-3:  6.3.6.2


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author is a person
<author typeCode="AUT" contextControlCode="OP">
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    <!-- ... -->
  </assignedAuthor>
</author>
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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
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0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
The name(s) SHALL be given.
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0 … 1FPSN
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PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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cs0 … 1FDEV
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cs0 … 1FINSTANCE
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SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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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 (2005‑09‑07)
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
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0 … 1FINSTANCE
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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
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TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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0 … 1FPART
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II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
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
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0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
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II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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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
Treetree.pnghl7:entry
0 … *RSource: PaLM Suppl. APSR 2.0-3:  6.2.5.2
Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (2015‑08‑13 10:24:55)
PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
Treeblank.png where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue

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