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Template SpecimenProcedureStep

Beschreibung

Template CDA Procedure (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF)for Specimen procedure step in APSR2.This entry collects all the information of source, method and result of a specimen procedure from the collection out of the patient through the final product of a stained histologic section or cytologic smear on a glass slide, or a WSI of such a slide. It reflects the workflow and the probe tracking of a pathology laboratory.

Aktuelle Version

Id2.16.840.1.113883.2.6.60.6.10.10Gültigkeit gültig ab 2014‑07‑29 16:02:02
StatusKyellow.png EntwurfVersions-Label
NameSpecimenProcedureStepAnzeigenameSpecimen Procedure Step
BeschreibungTemplate CDA Procedure (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF)
for Specimen procedure step in APSR2.

This entry collects all the information of source, method and result of a specimen procedure from the collection out of the patient through the final product of a stained histologic section or cytologic smear on a glass slide, or a WSI of such a slide. It reflects the workflow and the probe tracking of a pathology laboratory.
KontextElternknoten des Template-Element mit Id 2.16.840.1.113883.2.6.60.6.10.10
KlassifikationCDA Entry Level Template
Offen/GeschlossenGeschlossen (nur definierte Elemente sind erlaubt)
Benutzt von / Benutzt
Benutzt von 3 Templates, Benutzt 4 Templates
Benutzt von Template-Id als NameVersion
2.16.840.1.113883.2.6.60.6.10.10ContainmentSpecimen Procedure Step2014‑07‑29 16:02:02
2.16.840.1.113883.2.6.60.6.10.3Link.pngProcedure Steps Section2014‑05‑13 19:33:12
2.16.840.1.113883.2.6.60.6.10.1Link.pngPathology Structured Report2014‑05‑13 11:57:57
Benutzt Template-Id als NameVersion
1.2.276.0.76.10.90014ContainmentCDAPerformerBodyDYNAMIC
1.2.276.0.76.10.90025ContainmentCDAAuthorBodyDYNAMIC
2.16.840.1.113883.2.6.60.6.10.15InklusionCDAParticipantBodyAPSR2DYNAMIC
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.306 (2005‑09‑07)
Beispiel
Specimen procedure step entry
<procedure classCode="PROC" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.1.2"/>
  <templateId root="1.3.6.1.4.1.19376.1.8.1.4.28"/>
  <!-- type of the procedure step, here collection -->
  <code code="432550005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Core needle biopsy of breast using ultrasound guidance (procedure)">
    <originalText>
      <reference value="#A7102400008"/>
    </originalText>  </code>  <effectiveTime/>
  <!-- Anatomic site -->
  <targetSiteCode code="664" codeSystem="1.3.6.1.4.1.19376.1.8.2.1" displayName="Lower outer quadrant" codeSystemName="PATHLEX">
    <qualifier>
      <name code="272741003" codeSystem="2.16.840.1.113883.6.96" displayName="laterality" codeSystemName="SNOMED-CT"/>
      <value code="24028007" codeSystem="2.16.840.1.113883.6.96" displayName="right" codeSystemName="SNOMED-CT"/>
    </qualifier>  </targetSiteCode>  <!-- Specimen collector: the surgeon in this case -->
  <performer/>
  <!-- the specimen collected -->
  <participant typeCode="PRD">
    <participantRole classCode="SPEC">
      <!-- specimen id -->
      <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="A7102400008"/>
      <playingEntity>
        <!-- need a code in PATHLEX for "part obtained from a biopsy -->
        <code code="373102004" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen from breast obtained by image guided core biopsy (specimen)" codeSystemName="SNOMED CT"/>
      </playingEntity>    </participantRole>  </participant>  <!-- Child procedure step: Production of block A1 -->
  <entryRelationship typeCode="COMP">
    <procedure classCode="PROC" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.3.1.2"/>
      <templateId root="1.3.6.1.4.1.19376.1.8.1.4.28"/>
      <!-- type of the procedure step, here sampling a tissue dice from the part for a block -->
      <code code="433465004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Sampling of tissue specimen (procedure)">
        <originalText>
          <reference value="#block_A_1"/>
        </originalText>      </code>      <effectiveTime/>
      <targetSiteCode code="85756007" codeSystem="2.16.840.1.113883.6.96" displayName="Body tissue structure (body structure)" codeSystemName="SNOMED CT">
        <qualifier>
          <!-- a series of codes in PATHLEX would help to describe the exact topographic source of the tissue obtained by trimming and sampling -->
          <name code="118169006" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen source topography (attribute)" codeSystemName="SNOMED-CT"/>
          <value code="255503000" codeSystem="2.16.840.1.113883.6.96" displayName="Entire (qualifier value)" codeSystemName="SNOMED-CT"/>
        </qualifier>      </targetSiteCode>      <!-- Specimen preparator: a member staff of the pathology lab -->
      <Performer/>
      <!-- the specimen produced -->
      <participant typeCode="PRD">
        <participantRole classCode="SPEC">
          <!-- specimen ids -->
          <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="block_A_1"/>
          <parentId root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="A7102400008"/>
          <playingEntity>
            <!-- need a code in PATHLEX for "block extracted from a part -->
            <code code="441652008" codeSystem="2.16.840.1.113883.6.96" displayName="Formalin-fixed paraffin-embedded tissue specimen (specimen)" codeSystemName="SNOMED CT"/>
          </playingEntity>        </participantRole>      </participant>    </procedure>  </entryRelationship></procedure>
ItemDTKardKonfBeschreibungLabel
hl7:procedure
1 … *R(SpecimenProcedureStep)
Treetree.png@classCode
cs1 … 1FPROC
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1R(SpecimenProcedureStep)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.12.306
Treetree.pnghl7:templateId
II1 … 1M(SpecimenProcedureStep)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.2.6.60.6.10.10
Treetree.pnghl7:id
II0 … *(SpecimenProcedureStep)
Treetree.pnghl7:code
CD1 … 1R(SpecimenProcedureStep)
 Constraintfor specimen collection procedure codes for targetSite or PathLex or SNOMED CT have to be used, for specimen processing (down step the procedures) SNOMED CT is preferred, DICOM could be used if available
 CONF
@code muss "17636008" sein
@codeSystem muss "2.16.840.1.113883.6.96" sein
@displayName muss "Specimen collection (procedure)" sein
@codeSystemName muss "SNOMED CT" sein
oder
@code muss "40923002" sein
@codeSystem muss "2.16.840.1.113883.6.96" sein
@displayName muss "Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)" sein
@codeSystemName muss "SNOMED CT" sein
Treetree.pnghl7:text
ED0 … 1(SpecimenProcedureStep)
 Beispiel
specimen collection procedure
<text>ULTRASOUND GUIDED NEEDLE CORE BIOPSY</text>
 Beispiel
specimen processing procedure
<text>CUTTING A SLIDE FROM A PARAFFIN BLOCK</text>
Treetree.pnghl7:statusCode
CS0 … 1(SpecimenProcedureStep)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS0 … 1(SpecimenProcedureStep)
Treetree.pnghl7:methodCode
CE0 … *(SpecimenProcedureStep)
 CONF
@codeSystem muss "2.16.840.1.113883.5.1065" sein
oder
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.2.6.60.6.11.39 Specimen Collection and Processing (DYNAMIC)
Treetree.pnghl7:target​Site​Code
CD0 … *EN-US.png (SpecimenProcedureStep)
 CONF
@codeSystem muss "2.16.840.1.113883.5.1052" sein
oder
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.2.6.60.6.11.40 Procedure Site SCT (DYNAMIC)
Treetree.pnghl7:performer
0 … *Beinhaltet 1.2.276.0.76.10.90014 CDA Performer (Body) (DYNAMIC)(SpecimenProcedureStep)
Treetree.pnghl7:author
0 … *Beinhaltet 1.2.276.0.76.10.90025 CDA Author (Body) (DYNAMIC)(SpecimenProcedureStep)
Treetree.pnghl7:participant
0 … 1M

Notice.pngWarnung: Wenn isMandatory=true dann muss minimumMultiplicity größer 0 sein.

(SpecimenProcedureStep)
Eingefügt 1 … 1 Notwendig von 2.16.840.1.113883.2.6.60.6.10.15 CDA Participant (Body) APSR (DYNAMIC)
 Beispiel
Specimen collected or processed
<participant typeCode="PRD">
  <participantRole classCode="SPEC">
    <!-- specimen ids -->
    <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="A7102400008"/>
    <playingEntity>
      <!-- need a code in PATHLEX for "part obtained from a biopsy -->
      <code code="theCode" codeSystem="1.3.6.1.4.1.19376.1.8.2.1" displayName="part collected by biopsy" codeSystemName="PATHLEX"/>
    </playingEntity>  </participantRole></participant>
Treeblank.pngTreetree.png@typeCode
cs1 … 1FPRD
Treeblank.pngTreetree.png@context​Control​Code
1 … 1FOP
Treeblank.pngTreetree.pnghl7:time
IVL_TS1 … 1M(SpecimenProcedureStep)
Treeblank.pngTreetree.pnghl7:participantRole
1 … 1M(SpecimenProcedureStep)
Treeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FSPEC
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1MEN-US.png specimen id
(SpecimenProcedureStep)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … 1MEN-US.png parent id

Notice.pngWarnung: Wenn isMandatory=true dann muss minimumMultiplicity größer 0 sein.

(SpecimenProcedureStep)
 ConstraintThis Id is the paraentId, i.e. the id of the parent of this specimen. It is not given in specimen collection procedure.
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1optional for specimen collection procedure
(SpecimenProcedureStep)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
1 … 1FP
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.5.111 (Role Code)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
1 … 1FHL7
Eingefügt 0 … * von 2.16.840.1.113883.2.6.60.6.10.16 CDA PlayingEntity APSR2 (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FENT
Treeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … *Codes for
- classCode
- typeCode
- subTypeCode
- isDerived
- specimenRole
- specimenChildRole
- specimenGroupCount
(SpecimenProcedureStep)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.16040 EntityCode (DYNAMIC)
oder
@code muss "see example " sein
oder
@code muss "119376003" sein
@codeSystem muss "2.16.840.1.113883.6.96" sein
@displayName muss "Tissue, unspecified" sein
@codeSystemName muss "SNOMED-CT" sein
oder
@code muss "TISS" sein
@codeSystem muss "2.16.840.1.113883.5.129" sein
@codeSystemName muss "HL7" sein
 Beispiel
example for PathLex
<playingEntity>
  <!-- Need codes in PathLex for "part obtained by e.g.biopsy" -->
  <code code="theCode" codeSystem="1.3.6.1.4.1.19376.1.8.2.1" displayName="part collected by e.g.biopsy" codeSystemName="PathLex"/>
</playingEntity>
Treeblank.pngTreeblank.pngTreetree.pnghl7:quantity
PQ0 … *(SpecimenProcedureStep)
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
PN0 … *(SpecimenProcedureStep)
Treeblank.pngTreeblank.pngTreetree.pnghl7:desc
ED0 … *(SpecimenProcedureStep)
Treetree.pnghl7:entryRelationship
0 … 2Beinhaltet 2.16.840.1.113883.2.6.60.6.10.10 Specimen Procedure Step (DYNAMIC)(SpecimenProcedureStep)

Zusammenstellung aller Versionen dieses Templates

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