2.16.840.1.113883.2.6.60.6.10.9/static-2014-05-14T170954

Id	2.16.840.1.113883.2.6.60.6.10.9	Gültigkeit	gültig ab 2014‑05‑14 17:09:54
Status	Entwurf	Versions-Label
Name	APObservationEntry	Anzeigename	AP Observation Entry
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.
Kontext	Elternknoten des Template-Element mit Id 2.16.840.1.113883.2.6.60.6.10.9
Klassifikation	CDA Entry Level Template
Offen/Geschlossen	Geschlossen (nur definierte Elemente sind erlaubt)
Assoziiert mit	Assoziiert mit 1 Konzept Id Name Datensatz psr-data​element-47 PSR
Benutzt von / Benutzt	Benutzt von 9 Templates, Benutzt 3 Templates Benutzt von Template-Id als Name Version 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 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
Beziehung	Spezialisierung: Template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
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>
Item DT Kard Konf Beschreibung Label hl7:observation 0 … * (APObservationEntry) @classCode 1 … 1 F OBS @moodCode cs 1 … 1 F EVN @negationInd bl 0 … 1     Ziel der Konzept Id(s): psr-data​element-47 PSR hl7:templateId II 1 … 1 R (APObservationEntry) @root 1 … 1 F 2.16.840.1.113883.10.12.303 hl7:templateId II 1 … 1 M (APObservationEntry) @root 1 … 1 F 2.16.840.1.113883.2.6.60.6.10.9 hl7:id II 0 … * (APObservationEntry) hl7:code CD 1 … 1 M (APObservationEntry) @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) @codeSystemName 1 … 1 F LOINC   Beispiel <code code="59847-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Histology and Behavior ICD-O-3"/> hl7:derivationExpr ST 0 … 1 (APObservationEntry) hl7:text ED 0 … 1 R Textual description of the observation, offered by the system (APObservationEntry) hl7:statusCode CS 0 … 1 (APObservationEntry)   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 R Date and time the observation has been made, offered by the system (APObservationEntry) hl7:priorityCode CE 0 … 1 (APObservationEntry)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.16866 Act Priority (DYNAMIC) hl7:repeatNumber IVL_INT 0 … 1 (APObservationEntry) hl7:language​Code CS 0 … 1 (APObservationEntry)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC) hl7:value CD 1 … 1 R (APObservationEntry)   Constraint The default data type, cardinalities and value set for the <value> element are dependant of the type of observation.   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.2.6.60.6.11.34 AP Observation (DYNAMIC)   Beispiel <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"/> hl7:interpretationCode CE 0 … * (APObservationEntry)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC) hl7:methodCode CE 0 … * (APObservationEntry)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.14079 ObservationMethod (DYNAMIC) hl7:target​Site​Code CD 0 … * (APObservationEntry) @codeSystem 1 … 1 F 2.16.840.1.113883.5.1052 (Act Site) hl7:specimen 1 … 1 M Beinhaltet 2.16.840.1.113883.2.6.60.6.10.13 Specimen Identification (DYNAMIC) (APObservationEntry) wo [not(@nullFlavor)]   Constraint in this entry template only "specimen role" is used with the id given in specimen procedure step entry for that specimen the observation is made on.   Beispiel 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> hl7:performer 0 … * Beinhaltet 1.2.276.0.76.10.90014 CDA Performer (Body) (DYNAMIC) (APObservationEntry) hl7:author 0 … * Beinhaltet 1.2.276.0.76.10.90025 CDA Author (Body) (DYNAMIC) (APObservationEntry)