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Version vom 4. Februar 2017, 03:44 Uhr

Id1.3.6.1.4.1.19376.1.8.1.2.7Effective Date valid from 2016‑06‑13 17:54:42
StatusKyellow.png DraftVersion Label2.0
NameReportTextualSummaryDisplay NameReport Textual Summary Section
DescriptionTemplate CDA Section (prototype, directly derived from POCD_RM000040 MIF)

The Report Textual Summary section is an optional sub-section of the Diagnostic Conclusion section. This section contains a textual summary of the AP report, which can be extracted from the document and inserted into other clinical documents. It addresses the use case where authors of other medical documents feel the need to include a segment such as "...the pathology report states '[...]'", the text content of this section filling the brackets.


ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.7
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 templates, Uses 1 template
Uses Template id as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA authorDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
ItemDTCardConfDescriptionLabel
hl7:section
0 … 1R(ReportTextualSummary)
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.png@moodCode
cs0 … 1FEVN
 Constraint

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

@code="35660-0" 

@codeSystem="2.16.840.1.113883.6.1" 

@displayName="Pathology report final diagnosis section - text"  

This section SHALL contains a narrative block, represented by a text element, which renders the information to the human reader.

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

The section SHALL does not contain any entry element or any sub-section. 


Treetree.pnghl7:templateId
II1 … 1M(ReportTextualSummary)
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.7
Treetree.pnghl7:templateId
II1 … 1R(ReportTextualSummary)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.12.201
Treetree.pnghl7:id
II0 … 1R(ReportTextualSummary)
Treetree.pnghl7:code
CE1 … 1M(ReportTextualSummary)
Treeblank.pngTreetree.png@code
CONF1 … 1F35660-0
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@displayName
1 … 1FPathology report final diagnosis section - text
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treetree.pnghl7:title
ST1 … 1R(ReportTextualSummary)
 CONF
element content shall be "Report Textual Summary"
Treetree.pnghl7:text
SD.TEXT1 … 1M(ReportTextualSummary)
Treetree.pnghl7:confidentialityCode
CE0 … 1(ReportTextualSummary)
 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
CS0 … 1(ReportTextualSummary)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
Treetree.pnghl7:author
0 … *CSource: PAT TF-3:6.2.6.2(ReportTextualSummary)
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author (DYNAMIC)
Treeblank.pngTreetree.pnghl7:author
0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs0 … 1FAUT
Treeblank.pngTreeblank.pngTreetree.png@context​Control​Code
cs0 … 1FOP
 Target.pngAssociated with concepts:
psr-data​element-4PathologistAPSR 2.0
psr-data​element-79DeviceAPSR 2.0
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor>
</author>
Treeblank.pngTreeblank.pngTreetree.pnghl7:functionCode
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.pnghl7:time
TS.​DATE.​MIN1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 Example
author is a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>
</representedOrganization>
Included from 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author