| Id | 2.16.840.1.113883.2.6.60.6.10.7 | Gültigkeit | gültig ab 2014‑05‑13 11:57:09 |
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| Status |  Entwurf | Versions-Label | |
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| Name | MacroscopySection | Anzeigename | Macroscopic Observation Section |
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| Beschreibung | The Macroscopic Observation section contains the description of the specimen(s) received or obtained by the laboratory (specimen type and state), the gross observation, links to gross images, if taken, processing information and tissue disposition (representative sampling and tissue submitted for additional studies or sent to biorepository. |
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| Kontext | Elternknoten des Template-Element mit Id 2.16.840.1.113883.2.6.60.6.10.7 |
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| Klassifikation | CDA Section level template |
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| Offen/Geschlossen | Offen (auch andere als die definierten Elemente sind erlaubt) |
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| Assoziiert mit | | Assoziiert mit 1 Konzept | | Id | Name | Datensatz |
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| psr-dataelement-30 | | PSR |
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| Benutzt von / Benutzt | | Benutzt von 1 Template, Benutzt 1 Template | | Benutzt von Template-Id | als | Name | Version |
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| 2.16.840.1.113883.2.6.60.6.10.1 | Containment | Pathology Structured Report | 2014‑05‑13 11:57:57 | | Benutzt Template-Id | als | Name | Version |
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| 2.16.840.1.113883.2.6.60.6.10.34 | Containment | ProblemOrganizer | DYNAMIC |
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| Beziehung | Spezialisierung: Template 2.16.840.1.113883.10.12.201 (2005‑09‑07) |
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| Beispiel | | Beispiel | <section>
<templateId root="2.16.840.1.113883.10.12.201"/>
<templateId root="2.16.840.1.113883.2.6.60.6.10.7"/>
<code code="22634-0" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report gross observation"/>
<title>Macroscopic Observation</title> <text> Part #1 is labeled “left breast biopsy” and is received fresh after frozen section preparation. It consists of a single firm nodule measuring 3cm in circular diameter and 1.5cm in thickness surrounded by adherent fibrofatty tissue. On section a pale gray, slightly mottled appearance is revealed. Numerous sections are submitted for permanent processing. Part #2 is labeled "apical left axillary tissue" and is received fresh. It consists of two amorphous fibrofatty tissue masses without grossly discernible lymph nodes therein. Both pieces are rendered into numerous
sections and submitted in their entirety for history. </text></section> |
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| Item | DT | Kard | Konf | Beschreibung | Label |
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| | 0 … 1 | R | | (MacroscopySection) | | |  | Ziel der Konzept Id(s): |  | hl7:templateId
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| II | 1 … 1 | R | | (MacroscopySection) |  | | @root
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| | 1 … 1 | F | 2.16.840.1.113883.10.12.201 | | hl7:templateId
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| II | 1 … 1 | M | | (MacroscopySection) | | | @root
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| | 1 … 1 | F | 2.16.840.1.113883.2.6.60.6.10.7 | | hl7:id
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| II | 0 … 1 | | | (MacroscopySection) | | hl7:code
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| CE | 1 … 1 | R | | (MacroscopySection) | | | @code
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| | 1 … 1 | F | 22634-0 | | | @codeSystem
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| | 1 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) | | | @displayName
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| | 1 … 1 | F | Pathology report gross observation | | | @codeSystemName
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| | 1 … 1 | F | LOINC | | hl7:title
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| ST | 0 … 1 | R | | (MacroscopySection) | | | CONF | | Elementinhalt muss "Macroscopic observation" sein |
| | | Beispiel | <title>Macroscopic Observation</title> | | hl7:text
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| SD.TEXT | 0 … 1 | R | | (MacroscopySection) | | | Beispiel | <text> Part #1 is labeled “left breast biopsy” and is received fresh after frozen section preparation. It consists of a single firm nodule measuring 3cm in circular diameter and 1.5cm in thickness surrounded by adherent fibrofatty tissue. On section a pale gray, slightly mottled appearance is revealed. Numerous sections are submitted for permanent processing. Part #2 is labeled "apical left axillary tissue" and is received fresh. It consists of two amorphous fibrofatty tissue masses without grossly discernible lymph nodes therein. Both pieces are rendered into numerous
sections and submitted in their entirety for history. </text> | | hl7:entry
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| | 0 … * | | Beinhaltet 2.16.840.1.113883.2.6.60.6.10.34 Problem Organizer (DYNAMIC) | (MacroscopySection) | | | @typeCode
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| cs | 1 … 1 | R | | | | CONF | | Der Wert von @typeCode muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC) |
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Entwurf
