1.3.6.1.4.1.19376.1.8.1.4.9/static-2014-05-14T170954: Unterschied zwischen den Versionen

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     <p class="MsoBodyText" style="MARGIN: 6pt 0cm 0pt">An AP observation has a status and an effective time, may describe various participants (persons, devices, organizations), may have a number of additional properties (method, interpretation, text), and may contain embedded images, comments, and sub-observations, which are also AP observations.<br />
 
     <p class="MsoBodyText" style="MARGIN: 6pt 0cm 0pt">An AP observation has a status and an effective time, may describe various participants (persons, devices, organizations), may have a number of additional properties (method, interpretation, text), and may contain embedded images, comments, and sub-observations, which are also AP observations.<br />
 
     </p>
 
     </p>
</span></div></td></tr></table></td><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 1.3.6.1.4.1.19376.1.8.1.4.9</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Label</th><td style="text-align: left;" colspan="3">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation<br /></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 0 transactions and 9 templates, Uses 9 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</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;">1.3.6.1.4.1.19376.1.8.1.3.6</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] 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|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] 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|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Anatomic Pathology Structured Report Content Module (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|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] 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|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] 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|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] 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|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] 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|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Diagnostic Conclusion Section (2.0)</td><td style="text-align: left;">2014‑05‑13 19:31:26</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.9</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] AP Observation Entry (2.0)</td><td style="text-align: left;">2014‑05‑14 17:09:54</td></tr><tr><td style="text-align: left;"></td><td style="text-align: left;" colspan="3">[[File:Notice.png|16px]] Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check</td></tr><tr><th style="width: 20%; text-align: left;">Uses</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;">1.3.6.1.4.1.19376.1.3.3.1.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Laboratory Performer (2017)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.2</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] CDA author IHE</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|14px]] 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|14px]] Additional participant in an entry APSR (Body)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.9</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] AP Observation Entry (2.0)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.10</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Embedded Image IHE</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">2.16.840.1.113883.10.12.307</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] CDA RegionOfInterest</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.5.3.1.4.2</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] IHE Comment Entry (2014)</td><td style="text-align: left;">DYNAMIC</td></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|14px]] X Specimen Identified</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">Specialization: template 2.16.840.1.113883.10.12.303 <i> </i> (2005‑09‑07)</td></tr><tr class="explabel" style="vertical-align: top;"><td style="width: 20em; text-align: left;">Example</td><td colspan="3" class="explabelgreen"><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">Observation example for use case #1, estrogen receptor</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">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="ppattribute">negationInd</span><span class="ppsign">="</span><span class="ppcontent">false</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">1.3.6.1.4.1.19376.1.8.1.4.9</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="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">16112-5</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Estrogen receptor [Interpretation] in Tissue</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">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">completed</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">20161129162112</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">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">CD</span><span class="ppsign">"</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">416053008</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Estrogen receptor positive tumor (disorder)</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><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">0107</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Microscopy</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;" 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 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (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(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">entryRelationship</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent"></span><span class="ppsign">"</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent"></span><span class="ppsign">"</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent"></span><span class="ppsign">"</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</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 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>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM…tion</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>1 … 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="">PaLM…tion</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">1.3.6.1.4.1.19376.1.8.1.4.9</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>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM…tion</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> <span title="shall have coding strength &#34;CWE&#34;">CWE</span></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td><span style="text-align: justify; text-indent: -36px;">The Anatomic pathology observation code should be taken from a reference terminology, preferably the LOINC terminology. National terminologies may be used.</span></td><td style="background-color: #FFEEEE;"><span title="">PaLM…tion</span></td></tr><tr style="vertical-align: top;"><td><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>@code<br /></strong></tt></td></tr></table></td><td rowspan="4" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">each_code_for_observable_entities_or_a_specific_procedure</td></tr><tr style="vertical-align: top;"><td><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>@codeSystem<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)</td></tr><tr style="vertical-align: top;"><td><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>@codeSystemName<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">LOINC</td></tr><tr style="vertical-align: top;"><td><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>@displayName<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">see_above</td></tr><tr class="explabel" style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelgreen"><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">59847-4</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Histology and Behavior ICD-O-3</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: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>Narrative text about the observation</td><td style="background-color: #FFEEEE;"><span title="">PaLM…tion</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> <span title="shall have coding strength &#34;CNE&#34;">CNE</span></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td><span style="-webkit-text-stroke-color: rgb(0, 0, 0);">The observation statusCode is “completed” if the observation was actually performed and has produced a result in the </span>
+
</span></div></td></tr></table></td><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 1.3.6.1.4.1.19376.1.8.1.4.9</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Label</th><td style="text-align: left;" colspan="3">PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation<br /></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 0 transactions and 9 templates, Uses 9 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</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;">1.3.6.1.4.1.19376.1.8.1.3.6</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] 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|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] 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|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Anatomic Pathology Structured Report Content Module (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|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] 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|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] 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|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] 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|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] 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|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Diagnostic Conclusion Section (2.0)</td><td style="text-align: left;">2014‑05‑13 19:31:26</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.9</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] AP Observation Entry (2.0)</td><td style="text-align: left;">2014‑05‑14 17:09:54</td></tr><tr><td style="text-align: left;"></td><td style="text-align: left;" colspan="3">[[File:Notice.png|16px]] Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check</td></tr><tr><th style="width: 20%; text-align: left;">Uses</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;">1.3.6.1.4.1.19376.1.3.3.1.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Laboratory Performer (2017)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.2</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] CDA author IHE</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|14px]] 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|14px]] Additional participant in an entry APSR (Body)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.9</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] AP Observation Entry (2.0)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.10</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Embedded Image IHE</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">2.16.840.1.113883.10.12.307</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] CDA RegionOfInterest</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.5.3.1.4.2</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] IHE Comment Entry (2014)</td><td style="text-align: left;">DYNAMIC</td></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|14px]] X Specimen Identified</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">Specialization: template 2.16.840.1.113883.10.12.303 <i> </i> (2005‑09‑07)</td></tr><tr class="explabel" style="vertical-align: top;"><td style="width: 20em; text-align: left;">Example</td><td colspan="3" class="explabelgreen"><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">Observation example for use case #1, estrogen receptor</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">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="ppattribute">negationInd</span><span class="ppsign">="</span><span class="ppcontent">false</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">1.3.6.1.4.1.19376.1.8.1.4.9</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="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">16112-5</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Estrogen receptor [Interpretation] in Tissue</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">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">completed</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">20161129162112</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">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">CD</span><span class="ppsign">"</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">416053008</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Estrogen receptor positive tumor (disorder)</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><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">0107</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Microscopy</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;" 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 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (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(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">entryRelationship</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent"></span><span class="ppsign">"</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent"></span><span class="ppsign">"</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent"></span><span class="ppsign">"</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</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 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>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLMtion</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>1 … 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="">PaLMtion</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">1.3.6.1.4.1.19376.1.8.1.4.9</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>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLMtion</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> <span title="shall have coding strength &#34;CWE&#34;">CWE</span></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td><span style="text-align: justify; text-indent: -36px;">The Anatomic pathology observation code should be taken from a reference terminology, preferably the LOINC terminology. National terminologies may be used.</span></td><td style="background-color: #FFEEEE;"><span title="">PaLMtion</span></td></tr><tr style="vertical-align: top;"><td><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>@code<br /></strong></tt></td></tr></table></td><td rowspan="4" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">each_code_for_observable_entities_or_a_specific_procedure</td></tr><tr style="vertical-align: top;"><td><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>@codeSystem<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)</td></tr><tr style="vertical-align: top;"><td><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>@codeSystemName<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">LOINC</td></tr><tr style="vertical-align: top;"><td><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>@displayName<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">see_above</td></tr><tr class="explabel" style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelgreen"><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">59847-4</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Histology and Behavior ICD-O-3</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: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>Narrative text about the observation</td><td style="background-color: #FFEEEE;"><span title="">PaLMtion</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> <span title="shall have coding strength &#34;CNE&#34;">CNE</span></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td><span style="-webkit-text-stroke-color: rgb(0, 0, 0);">The observation statusCode is “completed” if the observation was actually performed and has produced a result in the </span>
 
<span style="-webkit-text-stroke-color: rgb(0, 0, 0);">value</span>
 
<span style="-webkit-text-stroke-color: rgb(0, 0, 0);">value</span>
 
<span style="-webkit-text-stroke-color: rgb(0, 0, 0);"> </span>
 
<span style="-webkit-text-stroke-color: rgb(0, 0, 0);"> </span>
<span style="-webkit-text-stroke-color: rgb(0, 0, 0);">element. In other cases the status of the intended observation is “aborted” and the result will never come.</span></td><td style="background-color: #FFEEEE;"><span title="">PaLM…tion</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 1.3.6.1.4.1.19376.1.3.11.2 (DYNAMIC)<table class="artdecor" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Alert.png|16px]]</td><td style="vertical-align: top;"><span style="color: red;"><strong>Error: Cannot find value set "1.3.6.1.4.1.19376.1.3.11.2"</strong></span></td></tr></table></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>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>Date and time the observation has been made<br /></td><td style="background-color: #FFEEEE;"><span title="">PaLM…tion</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>ANY</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Observation values using the appropriate data type.<br />
+
<span style="-webkit-text-stroke-color: rgb(0, 0, 0);">element. In other cases the status of the intended observation is “aborted” and the result will never come.</span></td><td style="background-color: #FFEEEE;"><span title="">PaLMtion</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 1.3.6.1.4.1.19376.1.3.11.2 (DYNAMIC)<table class="artdecor" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Alert.png|16px]]</td><td style="vertical-align: top;"><span style="color: red;"><strong>Error: Cannot find value set "1.3.6.1.4.1.19376.1.3.11.2"</strong></span></td></tr></table></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>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>Date and time the observation has been made<br /></td><td style="background-color: #FFEEEE;"><span title="">PaLMtion</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>ANY</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Observation values using the appropriate data type.<br />
 
<br />Numeric results use data type PQ, which includes the unit. The result is absent in case of ‘aborted’ observation.<br />
 
<br />Numeric results use data type PQ, which includes the unit. The result is absent in case of ‘aborted’ observation.<br />
<br /></td><td style="background-color: #FFEEEE;"><span title="">PaLM…tion</span></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">The default data type, cardinalities and value set for the &lt;value&gt; element are dependant on the type of observation.</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 1.3.6.1.4.1.19376.1.3.11.11 <i>AP Observation </i>(DYNAMIC)</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="explabelgreen"><div>for observation on tumor type</div><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">8500/3</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.43.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">ICD-O-3</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Invasive carcinoma of the breast, no special type</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:interpretationCode<br /></strong></tt></td></tr></table></td><td><strong>CE</strong> <span title="shall have coding strength &#34;CWE&#34;">CWE</span></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td><p style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51);">One or more codes interpreting the result, expressed with ObservationInterpretation vocabulary (e.g., H = high, L = low). </p>
+
<br /></td><td style="background-color: #FFEEEE;"><span title="">PaLMtion</span></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">The default data type, cardinalities and value set for the &lt;value&gt; element are dependant on the type of observation.</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 1.3.6.1.4.1.19376.1.3.11.11 <i>AP Observation </i>(DYNAMIC)</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="explabelgreen"><div>for observation on tumor type</div><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">8500/3</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.43.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">ICD-O-3</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Invasive carcinoma of the breast, no special type</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:interpretationCode<br /></strong></tt></td></tr></table></td><td><strong>CE</strong> <span title="shall have coding strength &#34;CWE&#34;">CWE</span></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td><p style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51);">One or more codes interpreting the result, expressed with ObservationInterpretation vocabulary (e.g., H = high, L = low). </p>
 
<ul style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51);">
 
<ul style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51);">
 
     <p style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51);">This element may be coded with other values than those of the ObservationInterpretation vocabulary, given that the coding strength is CWE (coded with exceptions).</p>
 
     <p style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51);">This element may be coded with other values than those of the ObservationInterpretation vocabulary, given that the coding strength is CWE (coded with exceptions).</p>
</ul></td><td style="background-color: #FFEEEE;"><span title="">PaLM…tion</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 2.16.840.1.113883.1.11.78 <i>ObservationInterpretation </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:methodCode<br /></strong></tt></td></tr></table></td><td><strong>CE</strong> <span title="shall have coding strength &#34;CWE&#34;">CWE</span></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="">PaLM…tion</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></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>II</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>C</strong></span></td><td>Performing lab<br />
+
</ul></td><td style="background-color: #FFEEEE;"><span title="">PaLMtion</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 2.16.840.1.113883.1.11.78 <i>ObservationInterpretation </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:methodCode<br /></strong></tt></td></tr></table></td><td><strong>CE</strong> <span title="shall have coding strength &#34;CWE&#34;">CWE</span></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="">PaLMtion</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></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>II</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>C</strong></span></td><td>Performing lab<br />
 
<br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF-3: 6.3.2.20</span>
 
<br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF-3: 6.3.2.20</span>
<br /><br />Contains 1.3.6.1.4.1.19376.1.3.3.1.7 <i>Laboratory Performer</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM…tion</span></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">The performing laboratory is present at this level only if this particular observation was performed by a (subcontractor) laboratory distinct from the one issuing the rest of the observations in this organizer.</span>
+
<br /><br />Contains 1.3.6.1.4.1.19376.1.3.3.1.7 <i>Laboratory Performer</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLMtion</span></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">The performing laboratory is present at this level only if this particular observation was performed by a (subcontractor) laboratory distinct from the one issuing the rest of the observations in this organizer.</span>
 
<br /></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>II</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>C</strong></span></td><td>Author<br />
 
<br /></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>II</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>C</strong></span></td><td>Author<br />
 
<br />
 
<br />
Zeile 20: Zeile 20:
 
     <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">Source: PaLM TF Suppl. APSR 2.0-3:</span>
 
     <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">Source: PaLM TF Suppl. APSR 2.0-3:</span>
 
     <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);"> 6.3.6.2</span>
 
     <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);"> 6.3.6.2</span>
</div><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.2 <i>CDA author IHE</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM…tion</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>II</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Informant<br />
+
</div><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.2 <i>CDA author IHE</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLMtion</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>II</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Informant<br />
 
<br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF Suppl. APSR 2.0-3</span>
 
<br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF Suppl. APSR 2.0-3</span>
 
<span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">: 6.3.6.5</span>
 
<span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">: 6.3.6.5</span>
<br /><br />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="">PaLM…tion</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>II</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Additional participants<br />
+
<br /><br />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="">PaLMtion</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>II</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Additional participants<br />
 
<br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF Suppl. APSR 2.0-3</span>
 
<br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF Suppl. APSR 2.0-3</span>
 
<span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">: 6.3.6.6</span>
 
<span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">: 6.3.6.6</span>
<br /><br />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="">PaLM…tion</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:entryRelationship<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>Sub-Observation<br />
+
<br /><br />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="">PaLMtion</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:entryRelationship<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>Sub-Observation<br />
 
<br />
 
<br />
 
<span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">The result obtained for an observation may lead to an additional AP observation to refine this result. This sub-observation is again an Anatomic Pathology Observation.</span>
 
<span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">The result obtained for an observation may lead to an additional AP observation to refine this result. This sub-observation is again an Anatomic Pathology Observation.</span>
Zeile 34: Zeile 34:
 
         <br />Source: </span>Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF Suppl. APSR 2.0-3</span>
 
         <br />Source: </span>Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF Suppl. APSR 2.0-3</span>
 
     <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">: 6.3.6.7</span>
 
     <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">: 6.3.6.7</span>
</div><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.9 <i>AP Observation Entry</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM…tion</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> where  <i> [hl7:observation [hl7:code [(@code='each_code_for_observable_entities_or_a_specific_procedure' and @codeSystem='2.16.840.1.113883.6.1')]]]</i></td></tr></table></td><td></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>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</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:entryRelationship<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>Embedded image. <br />
+
</div><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.9 <i>AP Observation Entry</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLMtion</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> where  <i> [hl7:observation [hl7:code [(@code='each_code_for_observable_entities_or_a_specific_procedure' and @codeSystem='2.16.840.1.113883.6.1')]]]</i></td></tr></table></td><td></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>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</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:entryRelationship<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>Embedded image. <br />
 
<br />
 
<br />
 
<span style="-webkit-text-stroke-color: rgb(0, 0, 0);">This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest. </span>
 
<span style="-webkit-text-stroke-color: rgb(0, 0, 0);">This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest. </span>
Zeile 46: Zeile 46:
 
         <br />
 
         <br />
 
     </span>
 
     </span>
</div><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.10 <i>Embedded Image IHE</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM…tion</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>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</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:entryRelationship<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>Region of Interest<br />
+
</div><br />Contains 1.3.6.1.4.1.19376.1.8.1.4.10 <i>Embedded Image IHE</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLMtion</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>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</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:entryRelationship<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>Region of Interest<br />
 
<br />
 
<br />
 
<br />
 
<br />
Zeile 56: Zeile 56:
 
         <br />
 
         <br />
 
     </span>
 
     </span>
</div><br />Contains 2.16.840.1.113883.10.12.307 <i>CDA RegionOfInterest</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM…tion</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> where  <i> [hl7:regionOfInterest [hl7:code [@code=doc('include/voc-2.16.840.1.113883.1.11.16117-DYNAMIC.xml')//valueSet [1]/conceptList/*/@code or @nullFlavor]]]</i></td></tr></table></td><td></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>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><span style="-webkit-text-stroke-color: rgb(0, 0, 0);">This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest. <br />In the latter case by an entryRelationship @typeCode="SUBJ"</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:entryRelationship<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>Annotation comment<br />
+
</div><br />Contains 2.16.840.1.113883.10.12.307 <i>CDA RegionOfInterest</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLMtion</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> where  <i> [hl7:regionOfInterest [hl7:code [@code=doc('include/voc-2.16.840.1.113883.1.11.16117-DYNAMIC.xml')//valueSet [1]/conceptList/*/@code or @nullFlavor]]]</i></td></tr></table></td><td></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>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><span style="-webkit-text-stroke-color: rgb(0, 0, 0);">This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest. <br />In the latter case by an entryRelationship @typeCode="SUBJ"</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:entryRelationship<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>Annotation comment<br />
 
<br />
 
<br />
 
<br />
 
<br />
Zeile 66: Zeile 66:
 
         <br />
 
         <br />
 
     </span>
 
     </span>
</div><br />Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 <i>IHE Comment Entry</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM…tion</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> where  <i> [hl7:act [hl7:code [(@code='48767-8' and @codeSystem='2.16.840.1.113883.6.1')]]]</i></td></tr></table></td><td></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">COMP</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Included</td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong>M</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)<br />Specimen identification<br /></td></tr><tr class="explabel" style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelgreen"><div>Example for specimen referencing</div><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">specimen</span><span class="ppsign">&gt;</span><br /><span style="display: block;">  <span style="color:green">&lt;!-- which specimen is used for this observation --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">specimenRole</span><span class="ppsign">&gt;</span><br /><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">1.3.6.1.4.1.19376.1.8.1.4.999999</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">slide_A_1_PR</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">specimenRole</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">specimen</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:specimen<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong>M</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; 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></table></td></tr></table>
+
</div><br />Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 <i>IHE Comment Entry</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLMtion</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> where  <i> [hl7:act [hl7:code [(@code='48767-8' and @codeSystem='2.16.840.1.113883.6.1')]]]</i></td></tr></table></td><td></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">COMP</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Included</td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong>M</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)<br />Specimen identification<br /></td></tr><tr class="explabel" style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelgreen"><div>Example for specimen referencing</div><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">specimen</span><span class="ppsign">&gt;</span><br /><span style="display: block;">  <span style="color:green">&lt;!-- which specimen is used for this observation --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">specimenRole</span><span class="ppsign">&gt;</span><br /><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">1.3.6.1.4.1.19376.1.8.1.4.999999</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">slide_A_1_PR</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">specimenRole</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">specimen</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:specimen<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong>M</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; 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></table></td></tr></table>

Version vom 23. November 2017, 03:20 Uhr

Id1.3.6.1.4.1.19376.1.8.1.4.9Effective Date valid from 2014‑05‑14 17:09:54
StatusKyellow.png DraftVersion Label2.0
NameAPObservationEntryDisplay NameAP Observation Entry
Description
This content module is usable within a Problem organizer.
   
The “AP Observation” generic template is usable for all AP observations, including ancillary techniques. 

An AP observation has a status and an effective time, may describe various participants (persons, devices, organizations), may have a number of additional properties (method, interpretation, text), and may contain embedded images, comments, and sub-observations, which are also AP observations.

ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.4.9
LabelPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 9 templates, Uses 9 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.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
1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA author IHEDYNAMIC
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
1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.8.1.4.10ContainmentKyellow.png Embedded Image IHEDYNAMIC
2.16.840.1.113883.10.12.307ContainmentKgreen.png CDA RegionOfInterestDYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.2ContainmentKgreen.png IHE Comment Entry (2014)DYNAMIC
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen IdentifiedDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Example
Observation example for use case #1, estrogen receptor
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.4.9"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="16112-5" codeSystem="2.16.840.1.113883.6.1" displayName="Estrogen receptor [Interpretation] in Tissue"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20161129162112"/>  </effectiveTime>
  <value xsi:type="CD" code="416053008" displayName="Estrogen receptor positive tumor (disorder)" codeSystem="2.16.840.1.113883.6.96"/>  <methodCode code="0107" displayName="Microscopy" codeSystem="2.16.840.1.113883.5.84"/>  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'CDA Performer IHE (Body)' (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(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>
  <entryRelationship xsi:type="" typeCode="COMP">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (dynamic) -->
  </entryRelationship>
  <entryRelationship xsi:type="" typeCode="COMP">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (dynamic) -->
  </entryRelationship>
  <entryRelationship xsi:type="" typeCode="COMP">
    <!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' (dynamic) -->
  </entryRelationship>
  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 0..* O -->
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … *RPaLMtion
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1MPaLMtion
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.9
Treetree.pnghl7:id
II0 … *RPaLMtion
Treetree.pnghl7:code
CE CWE1 … 1MThe Anatomic pathology observation code should be taken from a reference terminology, preferably the LOINC terminology. National terminologies may be used.PaLMtion
Treeblank.pngTreetree.png@code
CONF1 … 1Feach_code_for_observable_entities_or_a_specific_procedure
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1Fsee_above
 Example<code code="59847-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Histology and Behavior ICD-O-3"/>
Treetree.pnghl7:text
ED0 … 1RNarrative text about the observationPaLMtion
Treetree.pnghl7:statusCode
CS CNE1 … 1MThe observation statusCode is “completed” if the observation was actually performed and has produced a result in the 

value  

element. In other cases the status of the intended observation is “aborted” and the result will never come.
PaLMtion
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 (DYNAMIC)
Alert.pngError: Cannot find value set "1.3.6.1.4.1.19376.1.3.11.2"
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1MDate and time the observation has been made
PaLMtion
Treetree.pnghl7:value
ANY0 … *RObservation values using the appropriate data type.


Numeric results use data type PQ, which includes the unit. The result is absent in case of ‘aborted’ observation.


PaLMtion
 ConstraintThe default data type, cardinalities and value set for the <value> element are dependant on the type of observation.
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.11 AP Observation (DYNAMIC)
 Example
for observation on tumor type
<value code="8500/3" codeSystem="2.16.840.1.113883.6.43.1" codeSystemName="ICD-O-3" displayName="Invasive carcinoma of the breast, no special type"/>
Treetree.pnghl7:interpretationCode
CE CWE0 … 1R

One or more codes interpreting the result, expressed with ObservationInterpretation vocabulary (e.g., H = high, L = low). 

    This element may be coded with other values than those of the ObservationInterpretation vocabulary, given that the coding strength is CWE (coded with exceptions).

PaLMtion
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)
Treetree.pnghl7:methodCode
CE CWE0 … 1RPaLMtion
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (DYNAMIC)
Treetree.pnghl7:performer
II0 … 1CPerforming lab


Source: PaLM TF-3: 6.3.2.20



Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (DYNAMIC)
PaLMtion
 ConstraintThe performing laboratory is present at this level only if this particular observation was performed by a (subcontractor) laboratory distinct from the one issuing the rest of the observations in this organizer.
Treetree.pnghl7:author
II0 … *CAuthor


   Source: PaLM TF Suppl. APSR 2.0-3:
    6.3.6.2

Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (DYNAMIC)
PaLMtion
Treetree.pnghl7:informant
II0 … *RInformant


Source: PaLM TF 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)
PaLMtion
Treetree.pnghl7:participant
II0 … *RAdditional participants


Source: PaLM TF Suppl. APSR 2.0-3 : 6.3.6.6



Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry APSR (Body) (DYNAMIC)
PaLMtion
Treetree.pnghl7:entryRelationship
0 … *RSub-Observation


The result obtained for an observation may lead to an additional AP observation to refine this result. This sub-observation is again an Anatomic Pathology Observation.

   
       
Source: 
Source: PaLM TF Suppl. APSR 2.0-3 : 6.3.6.7

Contains 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (DYNAMIC)
PaLMtion
Treeblank.png where [hl7:observation [hl7:code [(@code='each_code_for_observable_entities_or_a_specific_procedure' and @codeSystem='2.16.840.1.113883.6.1')]]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7:entryRelationship
0 … *REmbedded image. 


This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest. 

Source: PaLM TF Suppl. APSR 2.0-3 : 6.3.6.8

   
       

Contains 1.3.6.1.4.1.19376.1.8.1.4.10 Embedded Image IHE (DYNAMIC)
PaLMtion
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7:entryRelationship
0 … *RRegion of Interest






   
       

Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (DYNAMIC)
PaLMtion
Treeblank.png where [hl7:regionOfInterest [hl7:code [@code=doc('include/voc-2.16.840.1.113883.1.11.16117-DYNAMIC.xml')//valueSet [1]/conceptList/*/@code or @nullFlavor]]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
 ConstraintThis observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest.
In the latter case by an entryRelationship @typeCode="SUBJ"
Treetree.pnghl7:entryRelationship
0 … *RAnnotation comment






   
       

Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (DYNAMIC)
PaLMtion
Treeblank.png where [hl7:act [hl7:code [(@code='48767-8' and @codeSystem='2.16.840.1.113883.6.1')]]]
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCOMP
Included1 … *M from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (DYNAMIC)
Specimen identification
 Example
Example for specimen referencing
<specimen>
  <!-- which specimen is used for this observation -->
  <specimenRole>
    <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="slide_A_1_PR"/>  </specimenRole>
</specimen>
Treetree.pnghl7:specimen
1 … *MRequired 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
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