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.
Kontext
Elternknoten des Template-Element mit Id 2.16.840.1.113883.2.6.60.6.10.10
Klassifikation
CDA Entry Level Template
Offen/Geschlossen
Geschlossen (nur definierte Elemente sind erlaubt)
<procedureclassCode="PROC"moodCode="EVN"> <templateIdroot="1.3.6.1.4.1.19376.1.3.1.2"/> <templateIdroot="1.3.6.1.4.1.19376.1.8.1.4.28"/> <!-- type of the procedure step, here collection --> <codecode="432550005"codeSystem="2.16.840.1.113883.6.96"codeSystemName="SNOMED-CT"displayName="Core needle biopsy of breast using ultrasound guidance (procedure)"> <originalText> <referencevalue="#A7102400008"/> </originalText></code><effectiveTime/> <!-- Anatomic site --> <targetSiteCodecode="664"codeSystem="1.3.6.1.4.1.19376.1.8.2.1"displayName="Lower outer quadrant"codeSystemName="PATHLEX"> <qualifier> <namecode="272741003"codeSystem="2.16.840.1.113883.6.96"displayName="laterality"codeSystemName="SNOMED-CT"/> <valuecode="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 --> <participanttypeCode="PRD"> <participantRoleclassCode="SPEC"> <!-- specimen id --> <idroot="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 --> <codecode="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 --> <entryRelationshiptypeCode="COMP"> <procedureclassCode="PROC"moodCode="EVN"> <templateIdroot="1.3.6.1.4.1.19376.1.3.1.2"/> <templateIdroot="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 --> <codecode="433465004"codeSystem="2.16.840.1.113883.6.96"codeSystemName="SNOMED-CT"displayName="Sampling of tissue specimen (procedure)"> <originalText> <referencevalue="#block_A_1"/> </originalText></code><effectiveTime/> <targetSiteCodecode="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 --> <namecode="118169006"codeSystem="2.16.840.1.113883.6.96"displayName="Specimen source topography (attribute)"codeSystemName="SNOMED-CT"/> <valuecode="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 --> <participanttypeCode="PRD"> <participantRoleclassCode="SPEC"> <!-- specimen ids --> <idroot="1.3.6.1.4.1.19376.1.8.1.4.999999"extension="block_A_1"/> <parentIdroot="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 --> <codecode="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>
Item
DT
Kard
Konf
Beschreibung
Label
hl7:procedure
1 … *
R
(SpecimenProcedureStep)
@classCode
cs
1 … 1
F
PROC
@moodCode
cs
1 … 1
F
EVN
@negationInd
bl
0 … 1
hl7:templateId
II
1 … 1
R
(SpecimenProcedureStep)
@root
uid
1 … 1
F
2.16.840.1.113883.10.12.306
hl7:templateId
II
1 … 1
M
(SpecimenProcedureStep)
@root
uid
1 … 1
F
2.16.840.1.113883.2.6.60.6.10.10
hl7:id
II
0 … *
(SpecimenProcedureStep)
hl7:code
CD
1 … 1
R
(SpecimenProcedureStep)
Constraint
for 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
hl7:text
ED
0 … 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>
hl7:statusCode
CS
0 … 1
(SpecimenProcedureStep)
CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
hl7:effectiveTime
IVL_TS
0 … 1
(SpecimenProcedureStep)
hl7:methodCode
CE
0 … *
(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)
hl7:targetSiteCode
CD
0 … *
(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)
Warnung: 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
<participanttypeCode="PRD"> <participantRoleclassCode="SPEC"> <!-- specimen ids --> <idroot="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 --> <codecode="theCode"codeSystem="1.3.6.1.4.1.19376.1.8.2.1"displayName="part collected by biopsy"codeSystemName="PATHLEX"/> </playingEntity></participantRole></participant>
@typeCode
cs
1 … 1
F
PRD
@contextControlCode
1 … 1
F
OP
hl7:time
IVL_TS
1 … 1
M
(SpecimenProcedureStep)
hl7:participantRole
1 … 1
M
(SpecimenProcedureStep)
@classCode
0 … 1
F
SPEC
hl7:id
II
1 … 1
M
specimen id
(SpecimenProcedureStep)
hl7:id
II
0 … 1
M
parent id
Warnung: Wenn isMandatory=true dann muss minimumMultiplicity größer 0 sein.
(SpecimenProcedureStep)
Constraint
This Id is the paraentId, i.e. the id of the parent of this specimen. It is not given in specimen collection procedure.
hl7:code
CE
0 … 1
optional for specimen collection procedure
(SpecimenProcedureStep)
@code
1 … 1
F
P
@codeSystem
1 … 1
F
2.16.840.1.113883.5.111 (Role Code)
@codeSystemName
1 … 1
F
HL7
Eingefügt 0 … *
von 2.16.840.1.113883.2.6.60.6.10.16 CDA PlayingEntity APSR2 (DYNAMIC)
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" --> <codecode="theCode"codeSystem="1.3.6.1.4.1.19376.1.8.2.1"displayName="part collected by e.g.biopsy"codeSystemName="PathLex"/> </playingEntity>