Template APObservationEntry
Beschreibung
Template CDA Observation (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF).This Content Module is usable within a Problem Organizer.The “AP Observation” generic template is usable for all AP observations, including ancillary techniques.Each specific AP observation is associated to a specific template, child of the “AP Observation” generic template. This specific child template has exactly the same structure as the generic one, and brings only a number of vocabulary constraints related to the type of observation and to the type of organ source of the specimen observed: The code for the specific observation, defined as a value set bound to the observation/code element, containing a single triplet (code, codeSystem, displayName) representing this specific observation.The cardinalities and default type for the observation/value element carrying the results of this observation.The domain of values for this observation in case these values are coded. This domain of coded values is defined as a value set bound to the observation/value element, containing as many triplets (code, codeSystem, displayName) as there are admissible result values for this specific observation performed on a specimen taken from this specific organ.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.
Aktuelle Version
| Id | 2.16.840.1.113883.2.6.60.6.10.9 | Gültigkeit | gültig ab 2014‑05‑14 17:09:54 |
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| Status |  Entwurf | Versions-Label | |
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| Name | APObservationEntry | Anzeigename | AP Observation Entry |
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| Beschreibung | Template CDA Observation (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF).
This Content Module is usable within a Problem Organizer. The “AP Observation” generic template is usable for all AP observations, including ancillary techniques. Each specific AP observation is associated to a specific template, child of the “AP Observation” generic template. This specific child template has exactly the same structure as the generic one, and brings only a number of vocabulary constraints related to the type of observation and to the type of organ source of the specimen observed: - The code for the specific observation, defined as a value set bound to the observation/code element, containing a single triplet (code, codeSystem, displayName) representing this specific observation.
- The cardinalities and default type for the observation/value element carrying the results of this observation.
- The domain of values for this observation in case these values are coded. This domain of coded values is defined as a value set bound to the observation/value element, containing as many triplets (code, codeSystem, displayName) as there are admissible result values for this specific observation performed on a specimen taken from this specific organ.
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.
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| Kontext | Elternknoten des Template-Element mit Id 2.16.840.1.113883.2.6.60.6.10.9 |
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| Klassifikation | CDA Entry Level Template |
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| Offen/Geschlossen | Geschlossen (nur definierte Elemente sind erlaubt) |
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| Assoziiert mit | | Assoziiert mit 1 Konzept | | Id | Name | Datensatz |
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| psr-dataelement-47 | | PSR |
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| Benutzt von / Benutzt | | Benutzt von 9 Templates, Benutzt 3 Templates | | Benutzt von Template-Id | als | Name | Version |
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| 2.16.840.1.113883.2.6.60.6.10.36 | | TNM Grading | 2015‑11‑15 13:01:18 | | 2.16.840.1.113883.2.6.60.6.10.14 |  | TNM Observation | 2014‑05‑13 15:45:13 | | 2.16.840.1.113883.2.6.60.6.10.34 | | Problem Organizer | 2015‑08‑13 10:24:55 | | 2.16.840.1.113883.2.6.60.6.10.2 | | Intraoperative Observation Section | 2014‑05‑13 19:29:16 | | 2.16.840.1.113883.2.6.60.6.10.1 | | Pathology Structured Report | 2014‑05‑13 11:57:57 | | 2.16.840.1.113883.2.6.60.6.10.4 | | Diagnostic Conclusion Section | 2014‑05‑13 19:31:26 | | 2.16.840.1.113883.2.6.60.6.10.5 | | Clinical Information Section | 2014‑05‑13 14:38:08 | | 2.16.840.1.113883.2.6.60.6.10.6 | | Microscopic Observation Section | 2014‑05‑13 14:25:17 | | 2.16.840.1.113883.2.6.60.6.10.7 | | Macroscopic Observation Section | 2014‑05‑13 11:57:09 | | Benutzt Template-Id | als | Name | Version |
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| 2.16.840.1.113883.2.6.60.6.10.13 | Containment | SpecimenIdentification | DYNAMIC | | 1.2.276.0.76.10.90014 | Containment | CDAPerformerBody | DYNAMIC | | 1.2.276.0.76.10.90025 | Containment | CDAAuthorBody | DYNAMIC |
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| Beziehung | Spezialisierung: Template 2.16.840.1.113883.10.12.303 (2005‑09‑07) |
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| Beispiel | | Observation example | <observation negationInd="false" classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.12.303"/>
<templateId root="2.16.840.1.113883.2.6.60.6.10.9"/>
<id root="1.2.3.999" extension="--example only--"/>
<code/>
<derivationExpr/>
<text/>
<statusCode code="normal"/>
<effectiveTime>
<low value="20141217162315"/>
</effectiveTime> <priorityCode code="A" displayName="ASAP" codeSystem="2.16.840.1.113883.5.7"/>
<repeatNumber/>
<languageCode code=""/>
<value xsi:type="CD"/>
<interpretationCode code="Carrier" displayName="Carrier" codeSystem="2.16.840.1.113883.5.83"/>
<methodCode code="0001" displayName="Complement fixation" codeSystem="2.16.840.1.113883.5.84"/>
<targetSiteCode/>
<subject>
<!-- template CDASubjectBody (dynamic) -->
</subject> <specimen>
<!-- template Specimen Identification (dynamic) -->
</specimen> <performer>
<!-- template CDAPerformerBody (dynamic) -->
</performer> <author>
<!-- template CDAAuthorBody (dynamic) -->
</author> <informant>
<!-- template CDAinformantBody (dynamic) -->
</informant> <participant>
<!-- template CDAParticipantBody (dynamic) -->
</participant> <entryRelationship negationInd="false" typeCode="CAUS" inversionInd="false" contextConductionInd="false">
<sequenceNumber value="1"/>
<seperatableInd value="false"/>
<reference>
<!-- template CDAReference (dynamic) -->
</reference> <precondition>
<!-- template CDAPrecondition (dynamic) -->
</precondition> <referenceRange typeCode="REFV">
<observationRange classCode="OBS" moodCode="EVN.CRT">
<code/>
<text/>
<value xsi:type="ANY"/>
<interpretationCode code="Carrier" displayName="Carrier" codeSystem="2.16.840.1.113883.5.83"/>
</observationRange> </referenceRange> </entryRelationship></observation> |
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