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Inhaltsverzeichnis

Foreword

This is a supplement to the IHE Pathology and Laboratory Medicine Technical Framework V7.0. Each supplement undergoes a process of public comment and trial implementation before being incorporated into the volumes of the Technical Frameworks.

This supplement is published on <Month XX, 2017> for Public Comment. Comments are invited and may be submitted at http://www.ihe.net/<domain>/<domain>comments.cfm. In order to be considered in development of the Trial Implementation version of the supplement, comments must be received by <Month XX, 201X>.

This supplement describes changes to the existing technical framework documents.

“Boxed” instructions like the sample below indicate to the Volume Editor how to integrate the relevant section(s) into the relevant Technical Framework volume.

Replace Section X.X by the following:

Where the amendment adds text, make the added text bold underline. Where the amendment removes text, make the removed text bold strikethrough. When entire new sections are added, introduce with editor’s instructions to “add new text” or similar, which for readability are not bolded or underlined.

General information about IHE can be found at: http://www.ihe.net.

Information about the IHE Pathology and Laboratory Medicine domain can be found at: http://ihe.net/IHE_Domains.

Information about the structure of IHE Technical Frameworks and Supplements can be found at: http://ihe.net/IHE_Process and http://ihe.net/Profiles.

The current version of the IHE Technical Framework (if applicable) can be found at: http://ihe.net/Technical_Frameworks.


<Comments may be submitted on IHE Technical Framework templates any time at http://ihe.net/ihetemplates.cfm. Please enter comments/issues as soon as they are found. Do not wait until a future review cycle is announced.

Introduction to this Supplement

This supplement complements volume 1 of the PaLM technical framework with the description of the APSR 2.0 content profile, and volumes 3 and 4 with the bindings, content modules and value sets, which specify this profile.


Open Issues and Questions

None yet


Closed Issues

APSR-07 – Representing the hierarchy of specimens in an entry : This APSR supplement enables to represent the hierarchy of specimens at the CDA level 3. The operations on specimen and production of child specimens are tracked in the “Procedure Steps” section, which has a level 3 entry.

APSR-10 – Observation related to multiple specimens: For example tumor staging may require combining data from multiple specimens (e.g., a breast excision with positive margins followed by a re-excision with clear margins – in this case the tumor size may be a composite of measurements from both specimens. Another example is staging of ovarian carcinomas with multiple biopsies of pelvis, peritoneum, nodes, omentum, etc.). To accommodate these use cases, each problem organizer as well as each observation may reference any number of specimens using the <specimen> child element. Each of these references may point to a detailed description of the specimen, in the "procedure steps" section.

APSR-11 – Derivative specimens:Specimens derived from primary specimens for ancillary studies, which may be sent to a reference lab or done in another part of the same institution, are included in the scope of this profile. The results produced on a derived specimen are attached to this specimen in the report.

VOLUME 1 - PROFILES

10 Anatomic Pathology Structured Report (APSR) Profile

This content profile describes an anatomic pathology structured report (APSR) as a digital document to be shared or exchanged between pathology laboratories and other care providers and institutions.

Anatomic pathology structured reports document the findings on specimens removed from patients for diagnostic or therapeutic reasons. This information can be used for patient care, clinical research and epidemiology. Standardizing and computerizing anatomic pathology reports is necessary to improve the quality of reporting and to facilitate the exchange and reuse of the content of these reports.

This content profile describes a digital anatomic pathology report shared in a human-readable format, which may include images, and which also contains findings and observations in a machine-readable format, to facilitate the integration of these into the database of a consumer system, and to enable the application of automated reasoning to this content.

The scope of this IHE content profile covers all fields of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as cytopathology.

Goldsmith, J.D., et al., “Reporting guidelines for clinical laboratory reports in surgical pathology” Arch Pathol Lab Med, 2008. 132(10): p. 1608-16, is the first source of specification for this content profile. This article delineates the required, preferred, and optional elements which should be included in any report of surgical pathology.

This source is complemented by the “cancer checklists” produced by the College of American Pathologists, and by the “comptes rendus d’anatomopathologie : données minimales à renseigner pour une tumeur primitive” produced by the French society of pathology (SFP [1]) for the French cancer institute (INCa [www.e-cancer.fr]), and by the German "Guideline Pathology / Neuropathology" (formerly TM-30) of the Sector Committee Pathology for the implementation of DIN EN ISO/EC 17020.

This profile has also benefited from the guidance on cancer AP reports provided by the North-American Association of Central Cancer Registries; some of the example snippets captured in the profile leverage the NAACCR Standards for Cancer Registries, Volume V, Pathology Laboratory Electronic Reporting.

10.1 APSR Actors/Transactions

This section defines the actors, transactions, and/or content modules in this profile. General definitions of actors are given in the Technical Frameworks General Introduction Appendix A published here.

Figure 10.1-1 shows the actors directly involved in the APSR Profile and the direction that the content is exchanged.

A product implementation using this profile must group actors from this profile with actors from a workflow or transport profile to be functional. The grouping of the content module described in this profile to specific actors is described in more detail in the “Required Actor Groupings” section below.


Fig.4.1.-1.jpg

Figure 10.1-1 APSR Actor Diagram


Table 10.1-1 lists the content module(s) defined in the APSR profile. To claim support with this profile, an actor shall support all required content modules (labeled “R”) and may support optional content modules (labeled “O”).


Table 10.1-1: <Profile Acronym>Profile - Actors and Content Modules

Actors Content Modules Optionality Reference
Content

Creator

Anatomic Pathology Structured Report 1.3.6.1.4.1.19376.1.8.1.1.1

R PaLM TF-3: 6.3.1.2
Content

Consumer

Anatomic Pathology Structured Report 1.3.6.1.4.1.19376.1.8.1.1.1

R PaLM TF-3: 6.3.1.2


10.1.1 Actor Descriptions and Actor Profile Requirements

Most requirements are documented in Content Modules (Volume 3). This section documents any additional requirements on profile’s actors.

10.2 APSR Actor Options

Options that may be selected for each actor in this profile are listed in the table 10.2-1. These options are further detailed in PCC Technical Framework Volume 2 as indicated in the rightmost column.

Table 10.2-1 Anatomic Pathology Structured Report - Actors and Options

Actor Option Name Reference
Content

Creator

None
Content

Consumer

View Option (1)

Document Import Option (1)

Section Import Option (1)

PCC TF-2:3.1.1

PCC TF-2:3.1.2

PCC TF-2:3.1.3

Note 1: The Content Consumer Actor shall support at least one of these options.


10.3 APSR Required Actor Groupings

An Actor from this profile (Column 1) shall implement all of the required transactions and/or content modules in this profile in addition to all of the transactions required for the grouped actor (Column 2).

In some cases, required groupings are defined as at least one of an enumerated set of possible actors; this is designated by merging column one into a single cell spanning multiple potential grouped actors. Notes are used to highlight this situation.

Section 10.5 describes some optional groupings that may be of interest for security considerations and section 10.6 describes some optional groupings in other related profiles.

Table 10.3-1: Anatomic Pathology Structured Report - Required Actor Groupings

XD-LAB Actor Actor to be grouped with Reference Content Bindings Reference
Content

Creator

ITI XDS.b Document Source

OR

ITI XDM Portable Media Creator

OR

ITI XDR Document Source

ITI TF-1:10


ITI TF-1:16


ITI TF-1:15

Content

Consumer

ITI XDS.b Document Consumer

OR

ITI XDM Portable Media Consumer

OR

ITI XDR Document Recipient

ITI TF-1:10


ITI TF-1:16


ITI TF-1:15

Note 1: Each actor of APSR SHALL be grouped with at least one of the ITI actors listed in its table row.


10.4 APSR Overview

10.4.1 Concepts

This content profile represents a common digital document model applicable to any structured report for surgical pathology in all fields of anatomic pathology (cancers, benign neoplasms, non-neoplastic conditions) as well as for cytopathology.

This common model is composed of a header conveying the context of care (patient, care providers, pathologists, laboratories, order, act documented …) and a body. The body organizes the human-readable content of the report in a number of sections. Each section may also provide machine-readable content in a repeatable “entry” embedded in the section. This common model defines the order of appearance, cardinalities and internal structure of each section, and of each entry embedded in each section.

Figure 10.4.1-1 shows this general model applicable to any pathology digital report.

10.4.1-1 FM.jpeg

Figure 10.4.1-1 Common model for a digital anatomic pathology structured report

Note 1: The only section that is mandatory is the Diagnostic Conclusion section.

10.4.2 Use Cases

10.4.2.1 Use case #1: Single Report

Anatomic pathology order fulfilled by a pathology laboratory produces a report.


10.4.2.1.1 Single Report Use Case Description

A surgeon removes a breast tumor from a patient, requests the procedure “breast surgical specimen - pathological examination” and sends the specimen(s) to the anatomic pathology laboratory. Specimens) are accessioned by the anatomic pathology laboratory. The staff performs a macroscopic examination of the specimens ; gross imaging is performed if needed. The specimens are processed for microscopic examination and other special ancillary techniques or tissue banking if needed. During the imaging interpretation process, microscopic imaging is performed if needed. At the end of the interpretation process the pathologist queries the Content Creator application for the appropriate APSR template, fills the form, binds some relevant images and/or regions of interest to specific observations, validates and signs the digital report.

10.4.2.1.2 Single Report Process Flow

Intentionally left blank

10.4.2.1.3 Single Report Example

A. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY):

INVASIVE ADENOCARCINOMA OF THE BREAST. HISTOLOGIC TYPE: DUCTAL. NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3. TUBULE FORMATION SCORE: 2. NUCLEAR PLEOMORPHISM SCORE: 2. MITOTIC RATE SCORE: 1.

IN-SITU CARCINOMA: EQUIVOCAL.

BREAST CANCER BIOMARKER STUDIES: PARAFFIN BLOCK NUMBER: A1.


ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8).

PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED SCORE = 8).

DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR EXPRESSION OF

EPIDERMAL GROWTH FACTOR RECEPTOR.

HER2/NEU IMMUNOHISTOCHEMISTRY: POSITIVE (3+) FOR OVEREXPRESSION OF HER2/NEU

ONCOPROTEIN.

10.4.2.2 Use Case #2: Multi-step Report

Reporting includes multiple successive steps.


10.4.2.2.1 Multi-step Report Use Case Description

A surgeon removes a breast tumor from a patient, requests the procedure “breast surgical specimen - frozen sections & pathological examination”, and “breast surgical specimen - pathological examination” and sends the specimen(s) to the anatomic pathology laboratory.

Specimens are accessioned by the anatomic pathology department. The staff performs a macroscopic examination of the specimens, gross imaging is performed if needed. The specimens are processed for intraoperative observation if needed, and tissue banking if needed (e.g., for research purpose). During the imaging interpretation process of frozen sections, microscopic imaging is performed if needed. At the end of the interpretation process, the pathologist queries the Content Creator for the appropriate APSR template, fills the intraoperative observation section, binds some relevant images and/or regions of interest to specific observation(s) if needed, validates and signs (i.e., legally authenticates) the preliminary APSR.

The day after, the specimen(s) are processed for microscopic examination and other special ancillary techniques if needed. During the imaging interpretation process, microscopic imaging is performed if needed. At the end of the interpretation process, pathologist queries the Content Creator for the preliminary APSR, fills the form, binds some relevant images and/or regions of interest to specific observation(s), validates and signs (i.e., legally authenticates) the final APSR.


10.4.2.2.2 Multi-step Report Process Flow

Intentionally left blank


10.5 APSR Security Considerations

See Appendix A of PaLM TF-1.


10.6 APSR Cross Profile Considerations

Intentionally left blank


VOLUME 3 – CONTENT MODULES

1 Introduction

The content of this entire section is copied from section 1 of Volume 3 of PaLM TF.

1.1 Overview of the Anatomic Pathology Technical Framework

Integrating the Healthcare Enterprise (IHE) is an international initiative to promote the use of standards to achieve interoperability among health information technology (HIT) systems and effective use of electronic health records (EHRs). IHE provides a forum for care providers, HIT experts and other stakeholders in several clinical and operational domains to reach consensus on standards-based solutions to critical interoperability issues. The primary output of IHE is system implementation guides, called IHE Profiles. IHE publishes each profile through a well-defined process of public review and trial implementation and gathers profiles that have reached final text status into an IHE Technical Framework, of which this volume is a part. For more general information regarding IHE, refer to IHE International website. It is strongly recommended that, prior to reading this volume, the reader familiarizes themselves with the concepts defined in the IHE Technical Frameworks General Introduction.

1.2 Intended Audience

The intended audience of IHE Technical Frameworks Volume 3 is:

  • IT departments of healthcare institutions
  • Technical staff of vendors participating in the IHE initiative
  • Experts involved in standards development

1.3 Overview of Technical Framework Volume 3

Volume 3 is comprised of several distinct sections:

  • Section 1 provides background and reference material.
  • Section 2 presents the conventions used in this volume to define the content modules.
  • Section 3 provides an overview of Content Modules and the terminology used.
  • Section 4 is reserved for domain unique Content Module specifications.
  • Section 5 lists the namespaces and identifiers defined or referenced and the vocabularies defined or referenced herein.
  • Section 6 defines the PaLM domain’s HL7 V3 CDA Content Modules in detail.
  • Section 7 defines the PaLM domain’s DICOM content modules in detail.
  • Section 8 defines other types of content modules.

The appendices in Volume 3 provide clarification of technical details of the IHE data model and transactions. A glossary of terms and acronyms used in the IHE Technical Framework, including those from relevant standards, is provided in the IHE Technical Frameworks General Introduction. Due to the length of the document, some domains may divide Volume 3 into smaller volumes labeled 3a, 3b, etc. In this case, the Volume 3 appendices are gathered in Volume 3x. Code and message samples may also be stored on the IHE ftp server. In this case, explicit links to the ftp server will be provided in the transaction text.

1.4 Comment Process

IHE International welcomes comments on this document and the IHE initiative. They can be submitted by sending an email to the co-chairs and secretary of the Pathology and Laboratory Medicine domain committees at palm@ihe.net

1.5 Copyright Licenses

IHE International hereby grants to each Member Organization, and to any other user of these documents, an irrevocable, worldwide, perpetual, royalty-free, nontransferable, nonexclusive, non-sublicensable license under its copyrights in any IHE profiles and Technical Framework documents, as well as any additional copyrighted materials that will be owned by IHE International and will be made available for use by Member Organizations, to reproduce and distribute (in any and all print, electronic or other means of reproduction, storage or transmission) such IHE Technical Documents. The licenses covered by this Copyright License are only to those copyrights owned or controlled by IHE International itself. If parts of the Technical Framework are included in products that also include materials owned or controlled by other parties, licenses to use those products are beyond the scope of this IHE document and would have to be obtained from that other party.

1.5.1 Copyright of Base Standards

IHE technical documents refer to and make use of a number of standards developed and published by several standards development organizations. All rights for their respective base standards are reserved by these organizations. This agreement does not supersede any copyright provisions applicable to such base standards. Health Level Seven, Inc. has granted permission to IHE to reproduce tables from the HL7 standard. The HL7 tables in this document are copyrighted by Health Level Seven, Inc. All rights reserved. Material drawn from these documents is credited where used.

1.6 Trademark

IHE® and the IHE logo are trademarks of the Healthcare Information Management Systems Society in the United States and trademarks of IHE Europe in the European Community. They may only be used with the written consent of the IHE International Board Operations Committee, which may be given to a Member Organization in broad terms for any use that is consistent with the IHE mission and operating principles.

1.7 Disclaimer Regarding Patent Rights

Attention is called to the possibility that implementation of the specifications in this document may require use of subject matter covered by patent rights. By publication of this document, no position is taken with respect to the existence or validity of any patent rights in connection therewith. IHE International is not responsible for identifying Necessary Patent Claims for which a license may be required, for conducting inquiries into the legal validity or scope of Patents Claims or determining whether any licensing terms or conditions provided in connection with submission of a Letter of Assurance, if any, or in any licensing agreements are reasonable or non-discriminatory. Users of the specifications in this document are expressly advised that determination of the validity of any patent rights, and the risk of infringement of such rights, is entirely their own responsibility. Further information about the IHE International patent disclosure process including links to forms for making disclosures is available here. Please address questions about the patent disclosure process to the secretary of the IHE International Board: secretary@ihe.net

1.8 History of Document Changes

Content Modules for the APSR 2.0 Profile:

  • Reconfiguration of the Document content module
  • Reconfiguration of the Procedure step section content module
  • Introduction of the Additionally Specified Observation section content module
  • Reconfiguration of the entry content modules "Problem organizer" and "Specimen procedure steps"
  • Introduction of child element content modules "X-specimen identified", "UICC/AJCC-TNM observation", "ICD-O-3 observation", "Assessment scales observation"
  • Renewal and completion of value sets.

Transformation of a real-world use case into a valid APSR 2.0 xml instance.

Finishing the Supplement ready to public comment.

2 Conventions

This document has adopted the following conventions for representing the framework concepts and specifying how the standards upon which the IHE Technical Framework is based shall be applied.

2.1 Content Module Modeling and Profiling Conventions

In order to maintain consistent documentation, modeling methods for IHE content modules and profiling conventions for frequently used standards are maintained as an appendix in the IHE Technical Frameworks General Introduction. Methods described include the standards conventions DICOM, HL7 v2.x, HL7 Clinical Document Architecture (CDA) Documents, etc. These conventions are critical to understanding this volume and should be reviewed prior to reading this text.

2.2 Additional Standards Profiling Conventions

This section defines profiling conventions for standards which are not described in the IHE Technical Frameworks General Introduction.
Not Applicable.

3 Content Modules Overview and Terminology

In the future, an appendix to the IHE Technical Frameworks General Introduction will provide an overview of Content Modules. In the interim, information may be available here.
The Pathology and Laboratory Medicine content modules are listed in the table below:
Table 3-1: Pathology and Laboratory Medicine Content Modules

Content Module Acronym Type of Content Modules Semantic Status
XD-LAB CDA R2 medical document Clinical Laboratory Structured Report Final Text
APSR CDA R2 medical document Anatomic Pathology Structured Report Public Comment

4 IHE Pathology and Laboratory Medicine Bindings

4.1 Medical Document Binding to XDS, XDM and XDR

The bindings of the content modules of the PaLM domain leverage the bindings specified by the Patient Care Coordination domain, in PCC TF Volume 2, section 4, with the addition of the constraints specified below.

4.1.1 XDSDocumentEntry Metadata

4.1.1.1 XDSDocumentEntry.eventCodeList

Append this paragraph at the end of the section.

For the APSR content module, The XDSDocumentEntry.eventCodeList provides a means to index anatomic pathology reports by reportable conditions (e.g., certain types of tumors…) so as to facilitate later queries in a registry of shared clinical documents. The conclusions coded in the entry element of the Diagnostic Conclusion section are good candidates for this metadata.

4.1.1.2 XDSDocumentEntry.formatCode

Append this paragraph at the end of the section.

For the APSR content module, The XDSDocumentEntry.formatCode SHALL be urn:ihe:palm:apsr:2016
The associated codingScheme SHALL be 1.3.6.1.4.1.19376.1.2.3

4.1.1.3 XDSDocumentEntry.parentDocumentRelationship

Append this paragraph at the end of the section.

For the APSR content module XDSDocumentEntry.parentDocumentRelationship is constrained to the "RPLC" value. When there is a parent document the current document is a new version of the parent document, replacing it.

  • Note 1: A non-final anatomic pathology report published in an XDS infrastructure will likely be replaced afterwards by the final report. When this event occurs, the Content Creator Actor SHALL apply the following rules:
    • ClinicalDocument/setId SHALL have the same value in the new report as in the replaced report.
    • ClinicalDocument/versionNumber SHALL be incremented in the replacing report (i.e. the final one).
    • ClinicalDocument/relatedDocument@typeCode attribute SHALL be valued ”RPLC”
    • ClinicalDocument/relatedDocument/parentDocument/id in the new report SHALL be equal to ClinicalDocument/ id of the replaced document.

The Document Source Actor SHALL apply the following rules on XDSDocumentEntry metadata:

    • The final report SHALL be associated with the previously published one, using RPLC relationship and the previous report SHALL be “Deprecated” as described in ITI TF-2:4.1.6.1.
  • Note 2: A non-final report can also be replaced by a more recent, albeit still non-final report. The rules above also apply in this case.
  • Note 3: A final report can also be replaced by a corrective final report. The rules above also apply in this case.

5 Namespaces and Vocabularies

5.1 OID tree of PAT TF

1.3.6.1.4.1.19376.1.81.3.6.1.4.1.19376.1.8 is the OID of the former IHE Anatomic Pathology domain, whereas 1.3.6.1.4.1.19376.1.81.3.6.1.4.1.19376.1.3 is the OID for PaLM domain :

All exchangeable objects specified by these domains are identified by OIDs built on these roots:


Branch 1.3.6.1.4.1.19376.1.8.1 is dedicated to CDA Content Modules created by the AP domain

       Sub-branch 1.3.6.1.4.1.19376.1.8.1.1 is the OID of the generic Document Content Module		
       Sub-branch 1.3.6.1.4.1.19376.1.8.1.2 is dedicated to Section Content Modules
       Sub-branch 1.3.6.1.4.1.19376.1.8.1.3 is dedicated to Entry Content Modules.
       Sub-branch 1.3.6.1.4.1.19376.1.8.1.3.6 is the OID of the Problem Organizer
       Sub-branch 1.3.6.1.4.1.19376.1.8.1.4 is dedicated to Element Content Modules	
       Sub-branch 1.3.6.1.4.1.19376.1.8.1.4.9 is the OID of the generic anatomic pathology (AP) observation template


Branch 1.3.6.1.4.1.19376.1.8.2 is dedicated to terminologies defined by AP domain

       Sub-branch 1.3.6.1.4.1.19376.1.8.2.1 is dedicated to PathLex, BUT THIS TEMPORARY VOCABULARY IS NO LONGER USED		

Branch 1.3.6.1.4.1.19376.1.8.5 is dedicated to Value Sets defined by AP domain.

Branch 1.3.6.1.4.1.19376.1.3.10 is dedicated to Templates newly defined by PaLM domain.

       Sub-branch 1.3.6.1.4.1.19376.1.3.10.1 is dedicated to CDA Document Level Templates
       Sub-branch 1.3.6.1.4.1.19376.1.3.10.2 is dedicated to CDA Header Level Templates
       Sub-branch 1.3.6.1.4.1.19376.1.3.10.3 is dedicated to CDA Section Level Templates
       Sub-branch 1.3.6.1.4.1.19376.1.3.10.4 is dedicated to CDA Entry Level Templates
       Sub-branch 1.3.6.1.4.1.19376.1.3.10.9 is dedicated to CDA Template Fragments/Supporting Templates

Branch 1.3.6.1.4.1.19376.1.3.11 is dedicated to Value Sets newly defined by PaLM domain.

Branch 1.3.6.1.4.1.19376.1.8.9 is used to identify instances in the examples of AP content built by the PaLM domain.


Notes on other IHE OIDs used in the AP domain:

nn

5.2 Terminologies and controlled coded vocabularies

This section lists the terminologies and the coded vocabularies referenced by this Volume 3.

Table 5.2-1 Anatomic Pathology Terminologies and Coded Vocabularies

codeSystem codeSystemName Description Owner
2.16.840.1.113883.6.1 LOINC Logical Observation Identifier Names and Codes Regenstrief Institute
2.16.840.1.113883.6.8 UCUM Unified Code for Units of Measure Regenstrief Institute, and the UCUM Organization
2.16.840.1.113883.6.96 SNOMED-CT Systematized Nomenclature of Medicine – Clinical Terms IHTSDO
1.3.6.1.4.1.19376.1.5.3.2 IHEActCode Vocabulary defined by IHE PCC in PCC TF-2:5.1.2, used for representing annotation comments in the report IHE PCC
2.16.840.1.113883.5.4 Act Code Codesystem for Acts HL7
2.16.840.1.113883.5.6 ActClass Codesystem for Act Classes HL7
2.16.840.1.113883.5.1052 Act Site Codesystem for Act Sites HL7
2.16.840.1.113883.5.1065 ProcedureMethod Codesystem for Procedure Methods HL7
2.16.840.1.113883.5.111 Role Code Codesystem for Role Codes HL7
2.16.840.1.113883.5.129 SpecimenType Codesystem for Specimen Types HL7
2.16.840.1.113883.5.84 ObservationMethod A code system that provides additional detail about the means or technique used to ascertain the observation HL7
2.16.840.1.113883.6.3 ICD-10 International Classification of Diseases revision 10 WHO
2.16.840.1.113883.6.43 ICD-O-3 International Classification of Diseases for Oncology revision 3 WHO
1.2.840.10008.2.16.4 DICOM controlled vocabulary The meanings of codes defined in DICOM, either explicitly or by reference to another part of DICOM or an external reference document or standard [2] DICOM
2.16.840.1.113883.15.6 TNM 7th edition Internationally agreed-upon standards to describe and categorize cancer stages and progression http://www.uicc.org/resources/tnm Union for International Cancer Control (UICC) & American Joint Committee on Cancer (AJCC)
2.16.840.1.113883.15.7 TNM 6th edition Internationally agreed-upon standards to describe and categorize cancer stages and progression http://www.uicc.org/resources/tnm Union for International Cancer Control (UICC) & American Joint Committee on Cancer (AJCC)
2.16.840.1.113883.15.8 TNM 5th edition Internationally agreed-upon standards to describe and categorize cancer stages and progression http://www.uicc.org/resources/tnm Union for International Cancer Control (UICC) & American Joint Committee on Cancer (AJCC)
2.16.840.1.113883.6.4 ICD-10-PCS International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) WHO
1.2.276.0.76.5.464 OPS 2017 Code lists to describe and categorize surgeries and procedures, adapted from WHO ICPM for Germany DIMDI (WHO)
2.16.840.1.113883.6.174 OMIM Code lists to describe and categorize human genes. OMIM is a comprehensive, authoritative compendium of human genes and genetic phenotypes that is freely available and updated daily. OMIM Johns Hopkins University School of Medicine [3]
1.2.276.0.76.3.1.131.1.5.1 DKG Coding Scheme Internationally agreed-upon code lists to describe and categorize cancer grading systems, adapted for Germany [4] DKG (Deutsche Krebsgesellschaft)
1.2.276.0.76.5.336 Grading / Differentiation scheme Code lists to describe and categorize Tumor grading according ICD-O-3, adapted for Germany HL7.de
1.2.276.0.76.5.401 Localization scheme for distant metastases Code lists to describe and categorize localization of metastases according UICC, adapted for Germany HL7.de

5.3 Value Sets

The value sets defined or referenced by this Volume 3 of the IHE PaLM TF Suppl. are listed in Volume 4.

5.4 Namespaces

5.4.1 Namespace protecting extensions to the CDA schema

There is currently one single extension to the CDA.xsd schema used in PAT TF-3. This extension has been created by IHE LAB and is protected by this particular namespace in document instances: xmlns:lab="urn:oid:1.3.6.1.4.1.19376.1.3.2"


5.5 References to Content Modules built outside of IHE PAT TF

The Content Modules specified in this Volume 3 of the PAT TF leverage a number of Content Modules (currently CDA templates) produced and maintained by other groups, including other domains of IHE. Table 5.5-1 lists them.

Table 5.5-1 External Content Modules referenced by PAT TF-3

templateId Standard Definition Source of Specification
1.3.6.1.4.1.19376.1.5.3.1.3.1 CDA R2 Reason for referral IHE PCC TF-2:6.3.3.1.2
1.3.6.1.4.1.19376.1.5.3.1.3.4 CDA R2 History of present illness IHE PCC TF-2:6.3.3.2.1
1.3.6.1.4.1.19376.1.5.3.1.3.6 CDA R2 Active Problems IHE PCC TF-2:6.3.3.2.3
1.3.6.1.4.1.19376.1.5.3.1.4.2 CDA R2 Annotation Comment IHE PCC TF-2:6.3.4.6
1.3.6.1.4.1.19376.1.3.3.1.7 CDA R2 Laboratory Performer IHE PaLM TF-3:6.3.2.20
1.3.6.1.4.1.19376.1.3.3.1.6 CDA R2 Ordering Provider (ordering physician) IHE PaLM TF-3:6.3.2.17
1.3.6.1.4.1.19376.1.3.3.1.4 CDA R2 Intended Recipient IHE PaLM TF-3:6.3.2.14
1.3.6.1.4.1.19376.1.3.1.6 CDA R2 Laboratory Observation IHE PaLM TF-3:6.3.4.13

5.6 IHE code and formatCode for Anatomic Pathology Document Template

Merge the content of this section into the current section 5.1.1 of PaLM TF volume 3.

Any AP structured report SHALL be associated with the metadata typeCode = “11526-1”, which is the LOINC code for “Pathology study”.

The table below lists the format codes, template identifiers and media types used by the IHE Profiles specified in the PaLM Technical Framework. Note that the code system for these codes is 1.3.6.1.4.1.19376.1.2.3 as assigned by the ITI Domain for codes used for the purposes of cross-enterprise document sharing (XDS). For more information see XDS Coding System (1.3.6.1.4.1.19376.1.2.3).

Profile formatCode Media Type Template ID
XD-LAB urn:ihe:lab:xd-lab:2008 text/xml 1.3.6.1.4.1.19376.1.3.3
APSR urn:ihe:palm:apsr:2016 text/xml 1.3.6.1.4.1.19376.1.8.1.1.1

6 PaLM HL7 CDA Content Modules

6.1 Conventions

  • In all Content Modules specified in this section, the abbreviation “AP” stands for “Anatomic Pathology”.

6.2 Folder Modules

Intentionally left blank

6.3 Content Modules

This section defines each IHE Pathology and Laboratory Medicine Content Module in detail, specifying the standards used and the information defined.

6.3.1 CDA Document Content Modules

All persons (including the patient) and organizations mentioned in the CDA Document Content Modules SHALL include the elements name, addr and telecom.

6.3.1.1 Clinical Laboratory Report Content Module

Section unchanged, as in PaLM TF-3

6.3.1.2 Anatomic Pathology Structured Report Content Module

This Document Content Module defines the base set of constraints that apply to all AP structured report, related to any kind of lesion or diagnostic. In other words, this is the generic template for any AP structured report.

The body of this Document Content Module has the hierarchy of sections and entries depicted by figure 4.1.2.1-1 in Volume 1.
The specification of this Document Content Module is built and published on Art-Decor

Id1.3.6.1.4.1.19376.1.8.1.2.1Effective Date valid from 2014‑05‑13 14:38:08
StatusKyellow.png DraftVersion Label2.0
NameClinicalInformationSectionDisplay NameClinical Information Section
Description
The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, reason for anatomic pathology procedure, clinical laboratory data, information about specimens collected in this case (including target site, performer, specimen type, specimen(s) clinical description, and tumor site in case of a cancer).
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.1
LabelPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 5 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.1.1ContainmentKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.5.3.1.3.1ContainmentKgreen.png IHE Reason for Referral Section (2014)2016‑09‑26 07:58:18
1.3.6.1.4.1.19376.1.5.3.1.3.4ContainmentKgreen.png IHE History of Present Illness Section (2014)2013‑01‑31
1.3.6.1.4.1.19376.1.5.3.1.3.6ContainmentKgreen.png IHE Active Problems Section (2014)2015‑10‑05 16:02:07
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example
generated example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.1"/>  <code code="22636-5" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report relevant history"/>  <title>CLINICAL INFORMATION SECTION</title>  <text/>  <languageCode/>  <entry xsi:type="ANY" typeCode="COMP" contextConductionInd="true">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->
  </entry>
  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->
  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.1 'IHE Reason for Referral Section' (2016-09-26T07:58:18) -->
  </component>
  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.4 'History of Present Illness Section' (2013-01-31T00:00:00)
-->
  </component>
  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.6 'IHE Active Problems Section' (2015-10-05T16:02:07) -->
  </component>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … 1RPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.png@moodCode
cs0 … 1FEVN
 Constraint

   This section SHALL contain a code element populated with these attributes:

@code="22636-5" 

@codeSystem="'2.16.840.1.113883.6.1" 

@displayName=" Pathology report relevant history”  

This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.

The section SHOULD contain as many Problem Organizer entry elements as there are problems (or groups thereof) to be described. These entries provide the machine-readable data corresponding to the narrative block.

This section MAY contain a number of elements component/section introducing sub-sections, each of these sub-sections providing a particular type of clinical information.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

Treetree.pnghl7:templateId
II1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.1
Treetree.pnghl7:code
CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Treeblank.pngTreetree.png@code
CONF1 … 1F22636-5
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1FPathology report relevant history
Treetree.pnghl7:title
ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
 CONF
element content shall be "CLINICAL INFORMATION SECTION"
 Example<title>CLINICAL INFORMATION</title>
Treetree.pnghl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
 Example<text> Tissue submitted: left breast biopsy and apical axillary tissue </text>
Treetree.pnghl7:language​Code
CS0 … 1PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (2014‑03‑26)
Treetree.pnghl7:entry
ANY0 … *RProblem organizer
Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (2015‑08‑13 10:24:55)
PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Treeblank.png where [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]]
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2
Treetree.pnghl7:author
0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.png@typeCode
cs1 … 1FAUT
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor>
</author>
Treeblank.pngTreetree.pnghl7:templateId
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
Treeblank.pngTreetree.pnghl7:time
TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:assignedAuthor
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1
The author is either an assigned person or an authoring device.
Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
The name(s) SHALL be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 Example
represented organization for author as a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>
</representedOrganization>
Included0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)
The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPART
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
CS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treetree.pnghl7:component
0 … 1Subsection

Source: PCC TF-2: 6.3.3.1.1
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.1 IHE Reason for Referral Section (2016‑09‑26 07:58:18)
PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Treeblank.png where [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.5.3.1.3.1']]]
Treetree.pnghl7:component
0 … 1Subsection



Source: PCC TF-2: 6.3.3.2.1
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 IHE History of Present Illness Section (2013‑01‑31)
PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Treeblank.png where [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.5.3.1.3.4']]]
Treetree.pnghl7:component
0 … 1Subsection

Source: PCC TF-2: 6.3.3.2.3
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.6 IHE Active Problems Section (2015‑10‑05 16:02:07)
PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Treeblank.png where [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.5.3.1.3.6'] and hl7:templateId [@root='2.16.840.1.113883.10.20.1.11']]]
6.3.1.2.1 General constraints that apply to APSR
  • When a section has a text element and one or more entry element, the content coded for machine-processing in the entries SHALL be completely transcribed into human-readable content in the text element.
  • Conversely the text element MAY contain pieces of information, which are not available in machine-readable format in any entry element of the section.
  • Information that is sent SHALL clearly identify distinctions between:

None

It is known with complete confidence that there are none. This indicates that the sender knows that there is no relevant information of this kind that can be sent.

None Known

None known at this time, but it is not known with complete confidence that none exist.

Asked but unknown

The information was requested but could not be obtained. Used mainly in the context where an observation was made but the result could not be determined.

Unknown

The information is not known, or is otherwise unavailable.

Other, not specified

The actual value does not belong to the assigned value set and is not reported at all by the author.

Other, specify

The actual value does not belong to the assigned value set and the author of the report provides this foreign value anyway.

Not applicable

No proper value is applicable in this context.

Sections that are required to be present but have no information should use one of the above phrases where appropriate in the text element.

Structural elements that are required but have no information shall provide a “nullFlavor” attribute coding the reason why the information is missing.

Situation nullFlavor HL7 Definition
Asked but unknown ASKU Information was sought but not found
Unknown UNK A proper value is applicable, but not known
Other, not specified OTH The actual value is not an element in the value domain of a variable. (e.g., concept not provided by required code system).
Not applicable NA No proper value is applicable in this context
Temporarily not available NAV Information is not available at this time but it is expected that it will be available later.


The two situations “None” and “None known” represent effective values, which are part of the related value sets.

The situation “Other, specify” can be handled in two ways in a coded data element:

  • Leaving empty the code attribute and providing the non-coded answer in the originalText attribute.
  • Providing a value coded from a different coding scheme, when the coding strength of the element is “CWE” (coded with extensions). The attributes code, displayName, codeSystem and codeSystemName then describe the foreign code.

For ancillary techniques, the situation “ not performed” or “none performed” is represented by nullFlavor = NAV.


6.3.1.2.2 Common structure for CDA APSR

Figure 6.3.1.2.2-1 summarizes the common structure of the first six CDA APSR Section Content Modules specified here. Regarding the machine-readable part, the figure highlights the organization of entries within a section and of observations within an entry. Specific details such as the structure of sub-sections are not shown on this global picture.


6.2.1.3-1-FO FM GH.jpeg

Figure 6.3.1.2.2-1 CDA APSR: common structure of machine-readable content for CDA APSR Section Content Modules except Procedure Step Content Module

Note 1: In order to facilitate a further de-identification process of CDA AP reports for some secondary use (biosurveillance, epidemiology…) the producer of an APSR SHOULD avoid populating any patient identification data (name, sex, birthdate, address …) into the body of the report (neither <entry> elements nor <text> elements). The appropriate location for patient identification data is the CDA header exclusively.

Note 2: The AP sections are those shown on figure 10.4.1-1 of Volume 1.

Note 3: The possible sub sections are shown on figure 10.4.1-1 of Volume 1.


Figure 6.3.1.2.2-2 shows the common structure of the Procedure Step Content Module specified here, too.

6.2.1.3-2-FO FM GH.jpeg

Figure 6.3.1.2.2-2 CDA APSR: common structure of machine-readable content for Procedure Step Content Module

6.3.2 Place Holder

Intentionally left blank

6.3.3 Place Holder

Intentionally left blank

6.3.4 CDA R2 <section> Content Modules

6.3.4.1 Clinical Information <section> - 1.3.6.1.4.1.19376.1.8.1.2.1

6.3.4.1.1 Definition and Purpose

The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, reason for anatomic pathology procedure, clinical laboratory data, specimen collection procedure including target site, performer, specimen type, specimen(s) clinical description, and tumor site in case of a cancer. The only entry for this section is the Problem Organizer Entry module.

6.3.4.1.2 Specification and Example
Id1.3.6.1.4.1.19376.1.8.1.2.1Effective Date valid from 2014‑05‑13 14:38:08
StatusKyellow.png DraftVersion Label2.0
NameClinicalInformationSectionDisplay NameClinical Information Section
Description
The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, reason for anatomic pathology procedure, clinical laboratory data, information about specimens collected in this case (including target site, performer, specimen type, specimen(s) clinical description, and tumor site in case of a cancer).
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.1
LabelPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 5 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.1.1ContainmentKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.5.3.1.3.1ContainmentKgreen.png IHE Reason for Referral Section (2014)2016‑09‑26 07:58:18
1.3.6.1.4.1.19376.1.5.3.1.3.4ContainmentKgreen.png IHE History of Present Illness Section (2014)2013‑01‑31
1.3.6.1.4.1.19376.1.5.3.1.3.6ContainmentKgreen.png IHE Active Problems Section (2014)2015‑10‑05 16:02:07
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example
generated example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.1"/>  <code code="22636-5" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report relevant history"/>  <title>CLINICAL INFORMATION SECTION</title>  <text/>  <languageCode/>  <entry xsi:type="ANY" typeCode="COMP" contextConductionInd="true">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->
  </entry>
  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->
  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.1 'IHE Reason for Referral Section' (2016-09-26T07:58:18) -->
  </component>
  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.4 'History of Present Illness Section' (2013-01-31T00:00:00)
-->
  </component>
  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.6 'IHE Active Problems Section' (2015-10-05T16:02:07) -->
  </component>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … 1RPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.png@moodCode
cs0 … 1FEVN
 Constraint

   This section SHALL contain a code element populated with these attributes:

@code="22636-5" 

@codeSystem="'2.16.840.1.113883.6.1" 

@displayName=" Pathology report relevant history”  

This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.

The section SHOULD contain as many Problem Organizer entry elements as there are problems (or groups thereof) to be described. These entries provide the machine-readable data corresponding to the narrative block.

This section MAY contain a number of elements component/section introducing sub-sections, each of these sub-sections providing a particular type of clinical information.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

Treetree.pnghl7:templateId
II1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.1
Treetree.pnghl7:code
CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Treeblank.pngTreetree.png@code
CONF1 … 1F22636-5
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1FPathology report relevant history
Treetree.pnghl7:title
ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
 CONF
element content shall be "CLINICAL INFORMATION SECTION"
 Example<title>CLINICAL INFORMATION</title>
Treetree.pnghl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
 Example<text> Tissue submitted: left breast biopsy and apical axillary tissue </text>
Treetree.pnghl7:language​Code
CS0 … 1PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (2014‑03‑26)
Treetree.pnghl7:entry
ANY0 … *RProblem organizer
Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (2015‑08‑13 10:24:55)
PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Treeblank.png where [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]]
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2
Treetree.pnghl7:author
0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.png@typeCode
cs1 … 1FAUT
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor>
</author>
Treeblank.pngTreetree.pnghl7:templateId
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
Treeblank.pngTreetree.pnghl7:time
TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:assignedAuthor
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1
The author is either an assigned person or an authoring device.
Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
The name(s) SHALL be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 Example
represented organization for author as a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>
</representedOrganization>
Included0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)
The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPART
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
CS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treetree.pnghl7:component
0 … 1Subsection

Source: PCC TF-2: 6.3.3.1.1
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.1 IHE Reason for Referral Section (2016‑09‑26 07:58:18)
PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Treeblank.png where [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.5.3.1.3.1']]]
Treetree.pnghl7:component
0 … 1Subsection



Source: PCC TF-2: 6.3.3.2.1
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 IHE History of Present Illness Section (2013‑01‑31)
PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Treeblank.png where [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.5.3.1.3.4']]]
Treetree.pnghl7:component
0 … 1Subsection

Source: PCC TF-2: 6.3.3.2.3
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.6 IHE Active Problems Section (2015‑10‑05 16:02:07)
PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Treeblank.png where [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.5.3.1.3.6'] and hl7:templateId [@root='2.16.840.1.113883.10.20.1.11']]]

6.3.4.2 Intraoperative Observation <section> - 1.3.6.1.4.1.19376.1.8.1.2.2

6.3.4.2.1 Definition and Purpose

The Intraoperative Observation section contains an intraoperative diagnosis for each specimen examined, the specimen identification and description, intraoperative observation procedure description (frozen section, gross examination, intraoperative cytology) and derived specimen dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, and electron microscopy). The only entry for this section is the Problem Organizer Entry module.

6.3.4.2.2 Specification and Example
Id1.3.6.1.4.1.19376.1.8.1.2.2Effective Date valid from 2014‑05‑13 19:29:16
StatusKyellow.png DraftVersion Label2.0
NameIntraoperativeObservationSectionDisplay NameIntraoperative Observation Section
Description
The Intraoperative Observation section contains an intraoperative diagnosis for each specimen examined, the specimen identification and description, intraoperative observation procedure description (frozen section, gross examination, intraoperative cytology) and derived specimen dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, and electron microscopy).
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.2
LabelPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 2 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.1.1ContainmentKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example
generated example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.2"/>  <code code="83321-0" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report intraoperative observation in Specimen Document"/>  <title>INTRAOPERATIVE OBSERVATION SECTION</title>  <text/>  <languageCode/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->
  <entry typeCode="COMP" contextConductionInd="true">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' Problem Organizer (2015-08-13T10:24:55) -->
  </entry>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … 1RPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
Treetree.png@classCode
cs1 … 1FDOCSECT
Treetree.png@moodCode
cs1 … 1FEVN
 Constraint

   This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.

The section SHOULD contain as many Problem Organizer entry elements as there are problems or groups thereof observed. These entries provide the machine-readable data corresponding to the narrative block.

This section does not contain any subsection.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

Treetree.pnghl7:templateId
II1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.2
Treetree.pnghl7:code
CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
Treeblank.pngTreetree.png@code
CONF1 … 1F83321-0
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1FPathology report intraoperative observation in Specimen Document
Treetree.pnghl7:title
ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
 CONF
element content shall be "INTRAOPERATIVE OBSERVATION SECTION"
Treetree.pnghl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
 Example
Intraoperative observation
<text>Frozen section diagnosis of infiltrating duct carcinoma, left breast</text>
Treetree.pnghl7:language​Code
CS0 … 1PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (2014‑03‑26)
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
Author
Source: PaLM Suppl. APSR 2.0-3: 

6.2.6.2


Treetree.pnghl7:author
0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.png@typeCode
cs1 … 1FAUT
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor>
</author>
Treeblank.pngTreetree.pnghl7:templateId
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
Treeblank.pngTreetree.pnghl7:time
TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:assignedAuthor
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1
The author is either an assigned person or an authoring device.
Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
The name(s) SHALL be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 Example
represented organization for author as a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>
</representedOrganization>
Included0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)
The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPART
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
CS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treetree.pnghl7:entry
0 … *RSource: PAT TF-3:6.2.6.8

Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (2015‑08‑13 10:24:55)
PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
Treeblank.png where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue

6.3.4.3 Macroscopic Observation <section> - 1.3.6.1.4.1.19376.1.8.1.2.3

6.3.4.3.1 Definition and Purpose

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. The only entry for this section is the Problem Organizer Entry module.

6.3.4.3.2 Specification and Example
Id1.3.6.1.4.1.19376.1.8.1.2.3Effective Date valid from 2014‑05‑13 11:57:09
StatusKyellow.png DraftVersion Label2.0
NameMacroscopySectionDisplay NameMacroscopic Observation Section
Description
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.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.3
LabelPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 2 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.1.1ContainmentKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example
Example
<section>
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.3"/>  <code code="22634-0" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report gross observation"/>  <title>MACROSCOPIC OBSERVATION SECTION</title>  <text/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->
  <entry typeCode="COMP">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->
  </entry>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … 1RPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
 Constraint

   This section SHALL contain a code element populated with these attributes:
   

@code ="22634-0"

@codeSystem ="2.16.840.1.113883.6.1"

@displayName ="Pathology report gross observation" 

This section does not contain any subsection. The section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.

The section SHOULD contain as many Problem Organizer entry elements as there are problems or groups thereof to be described. These entries provide the machine-readable data corresponding to the narrative block.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.3
Treetree.pnghl7:code
CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
Treeblank.pngTreetree.png@code
CONF1 … 1F22634-0
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1FPathology report gross observation
Treetree.pnghl7:title
ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
 CONF
element content shall be "MACROSCOPIC OBSERVATION SECTION"
 Example<title>Macroscopic Observation</title>
Treetree.pnghl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
 Example
example for use case #1
<text>A. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)</text>
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
Author


Source: PaLM Suppl. APSR 2.0-3:  6.3.6.2


Treetree.pnghl7:author
0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.png@typeCode
cs1 … 1FAUT
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor>
</author>
Treeblank.pngTreetree.pnghl7:templateId
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
Treeblank.pngTreetree.pnghl7:time
TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:assignedAuthor
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1
The author is either an assigned person or an authoring device.
Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
The name(s) SHALL be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
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cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 Example
represented organization for author as a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>
</representedOrganization>
Included0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)
The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPART
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
CS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
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II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treetree.pnghl7:entry
0 … *RSource: PaLM Suppl. APSR 2.0-3:  6.2.5.2
Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (2015‑08‑13 10:24:55)
PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
Treeblank.png where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue

6.3.4.4 Microscopic Observation <section> - 1.3.6.1.4.1.19376.1.8.1.2.4

6.3.4.4.1 Definition and Purpose

The Microscopic Observation section contains optionally the histopathologic findings of the case and many laboratories use this section to record the results of histochemical and immunohistochemical stains.The only entry for this section is the Problem Organizer Entry module.

6.3.4.4.2 Specification and Example
Id1.3.6.1.4.1.19376.1.8.1.2.4Effective Date valid from 2014‑05‑13 14:25:17
StatusKyellow.png DraftVersion Label2.0
NameMicroscopySectionDisplay NameMicroscopic Observation Section
Description
The Microscopic Observation section contains optionally the histopathologic findings of the case and of all of the derived specimens. This section should be used to record the results of histochemical and immunohistochemical stains and of image-based molecular methods.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.4
LabelPaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 2 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.1.1ContainmentKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example
Example
<section>
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.4"/>  <code code="22635-7" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report microscopic observation"/>  <title>MICROSCOPIC OBSERVATION SECTION</title>  <text/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->
  <entry>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->
  </entry>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … 1RPaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
 Constraint

   This section SHALL contain a code element populated with these attributes:
   

@code ="22635-7"

@codeSystem ="2.16.840.1.113883.6.1"

@displayName ="Pathology report microscopic observation" 

This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.

The section SHOULD contain as many Problem Organizer entry elements as there are problems or groups thereof to be described. These entries provide the machine-readable data corresponding to the narrative block.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

This section does not contain any subsections. 

Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.4
Treetree.pnghl7:code
CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
Treeblank.pngTreetree.png@code
CONF1 … 1F22635-7
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1FPathology report microscopic observation
Treetree.pnghl7:title
ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
 CONF
element content shall be "MICROSCOPIC OBSERVATION SECTION"
 Example<title>MICROSCOPIC OBSERVATION SECTION</title>
Treetree.pnghl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
 Example
example from use case#1
<text>
   INVASIVE ADENOCARCINOMA OF THE BREAST.  <br/>  
HISTOLOGIC TYPE: DUCTAL.
  <br/>  
NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3.
  <list>
    <item>TUBULE FORMATION SCORE: 2.</item>    <item>NUCLEAR PLEOMORPHISM SCORE: 2.</item>    <item>MITOTIC RATE SCORE: 1.</item>  </list>
  
IN-SITU CARCINOMA: EQUIVOCAL.
  <br/>  <br/>  
BREAST CANCER BIOMARKER STUDIES:
  <list>
    <item>PARAFFIN BLOCK NUMBER: A1.</item>    <item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED
SCORE = 8, Allred Percentage Score = 5, Allred Staining Score = 3).
</item>
    <item>PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED
SCORE = 8).
</item>
    <item>DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR
EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.
</item>
    <item>HER2/NEU IMMUNOHISTOCHEMISTRY: EQUIVOCAL (2+) FOR OVEREXPRESSION
OF HER2/NEU ONCOPROTEIN.
</item>
    <item>HER2/NEU FISH RESULTS: NOT AMPLIFIED.</item>  </list>
</text>
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
Author


Source: PaLM Suppl. APSR 2.0-3:  6.3.6.2


Treetree.pnghl7:author
0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.png@typeCode
cs1 … 1FAUT
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor>
</author>
Treeblank.pngTreetree.pnghl7:templateId
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
Treeblank.pngTreetree.pnghl7:time
TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:assignedAuthor
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cs0 … 1FASSIGNED
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II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1
The author is either an assigned person or an authoring device.
Elements to choose from:
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  • hl7:assigned​Authoring​Device
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0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
The name(s) SHALL be given.
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SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
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Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 Example
represented organization for author as a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>
</representedOrganization>
Included0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)
The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPART
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
CS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treetree.pnghl7:entry
0 … *RProblem organizer entry


Source: PaLM Suppl. APSR 2.0-3:

 6.2.5.2
Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (2015‑08‑13 10:24:55)
PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
Treeblank.png where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue

6.3.4.5 Additional Specified Observation <section> - 1.3.6.1.4.1.19376.1.3.10.3.1

6.3.4.5.1 Definition and Purpose

The Additional Specified Observation section includes additional pathologic finding(s) and the results of ancillary studies with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken. The only entry for this section is the Problem Organizer Entry module.

6.3.4.5.2 Specification and Example
Id1.3.6.1.4.1.19376.1.3.10.3.1Effective Date valid from 2016‑11‑13 14:28:08
StatusKyellow.png DraftVersion Label2.0
NameAdditionalSpecifiedObservationSectionDisplay NameAdditional Specified Observation Section
Description
Template CDA Section (prototype, directly derived from POCD_RM000040 MIF)

The Additional Specified Observation section includes additional pathologic finding(s) and the results of ancillary study(yes) with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken.  Further CDA content section modules as subsections are allowed. 
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.3.1
LabelPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 2 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.1.1ContainmentKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
RelationshipAdaptation: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example
generated example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.3.1"/>  <code code="xxxxx-x" codeSystem="2.16.840.1.113883.6.1" displayName="specified observation"/>  <title>ADDITIONAL SPECIFIED OBSERVATION SECTION</title>  <text/>  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016‑06‑21 14:02:11) -->
  </author>
  <entry typeCode="COMP" contextConductionInd="true">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->
  </entry>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … *RPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.png@moodCode
cs0 … 1FEVN
 Constraint

   This section SHALL contain a code element populated with these attributes:
   

@code ="xxxxx-x" (specific for the additional specified observation)

@codeSystem ="2.16.840.1.113883.6.1" 

@displayName ="Pathology report yyyyy (specific) observation"  

This section SHALL contain a narrative block, represented by a textelement, which renders the information to the human reader.

The section SHOULD contain as many Problem Organizer entry elements as there are problems or groups thereof to be described. These entries provide the machine-readable data corresponding to the narrative block.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

This section MAY contain subsections. 

Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.3.1
Treetree.pnghl7:code
CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
 ConstraintThe LOINC code SHALL be chosen according the specified observation type
Treeblank.pngTreetree.png@code
CONF1 … 1Fxxxxx-x
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1Fspecified observation
Treetree.pnghl7:title
ST1 … 1RTitle of the specified observationPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
 CONF
element content shall be "ADDITIONAL SPECIFIED OBSERVATION SECTION"
 Example
MP observation
<text>MOLECULAR PATHOLOGY OBSERVATION SECTION</text>
Treetree.pnghl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2 
Treetree.pnghl7:author
0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.png@typeCode
cs1 … 1FAUT
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor>
</author>
Treeblank.pngTreetree.pnghl7:templateId
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
Treeblank.pngTreetree.pnghl7:time
TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:assignedAuthor
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1
The author is either an assigned person or an authoring device.
Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
The name(s) SHALL be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 Example
represented organization for author as a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>
</representedOrganization>
Included0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)
The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPART
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
CS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treetree.pnghl7:entry
0 … *RSource: PaLM Suppl. APSR 2.0-3: 6.2.5.2

Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (2015‑08‑13 10:24:55)
PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Treeblank.png where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue

6.3.4.6 Diagnostic Conclusion <section> - 1.3.6.1.4.1.19376.1.8.1.2.5

6.3.4.6.1 Definition and Purpose

The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen sample or group of specimen samples are reported separately. This section may include diagrams and still images or virtual slides, if taken. In case of cancer, this section may also include a the cancer checklist. The only entry for this section is the Problem Organizer Entry module.

6.3.4.6.2 Specification and Example
Id1.3.6.1.4.1.19376.1.8.1.2.5Effective Date valid from 2014‑05‑13 19:31:26
StatusKyellow.png DraftVersion Label2.0
NameDiagnosticConclusionSectionDisplay NameDiagnostic Conclusion Section
Description
The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.5
LabelPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 3 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.1.1ContainmentKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.3.10.4.5ContainmentKyellow.png CDA Update Information Organizer (2.0)2017‑11‑14 15:22:14
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example
generated example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.5"/>  <code code="22637-3" codeSystem="2.16.840.1.113883.6.1" displayName="'Pathology report diagnosis"/>  <title>DIAGNOSTIC CONCLUSION SECTION</title>  <text/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->
  <entry>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) 1..* R-->
  </entry>
  <entry>
    <!-- template 1.3.6.1.4.1.19376.1.3.10.4.5 'Update Information Organizer' (2017-11-14T15:22:14) 0..1 R -->
  </entry>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
Treetree.png@classCode
cs1 … 1FDOCSECT
Treetree.png@moodCode
cs1 … 1FEVN
 Constraint

         This section SHALL contain a code element populated with these attributes:
         

@code ="22637-3"

@codeSystem ="2.16.840.1.113883.6.1"

@displayName ="Pathology report diagnosis" 

This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.

The section SHALL contain as many Problem Organizer entry elements as there are problems or groups thereof investigated. Each entry provides machine-readable data.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.5
Treetree.pnghl7:code
CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
Treeblank.pngTreetree.png@code
CONF1 … 1F22637-3
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1F'Pathology report diagnosis
Treetree.pnghl7:title
ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
 CONF
element content shall be "DIAGNOSTIC CONCLUSION SECTION"
Treetree.pnghl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
 Example
example for use case#1
<text>
  <paragraph> A1. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)
</paragraph>
  
INVASIVE ADENOCARCINOMA OF THE BREAST.
  <br/>  
HISTOLOGIC TYPE: DUCTAL.
  <br/>   NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3.
  <list>
    <item>TUBULE FORMATION SCORE: 2.</item>    <item>NUCLEAR PLEOMORPHISM SCORE: 2.</item>    <item>MITOTIC RATE SCORE: 1.</item>  </list>
  
ICD-O-CLASSIFICATION: C50.3 M8500/31
  <br/>  
IN-SITU CARCINOMA: EQUIVOCAL.
  <br/>  <br/>  
BREAST CANCER BIOMARKER STUDIES:
  <list>
    <item>PARAFFIN BLOCK NUMBER: A1.</item>    <item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED
SCORE = 8, Percentage stained tumor cells = 85%, Allred Staining Score = 3).
</item>
    <item>PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED
SCORE = 8).
</item>
    <item>DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR
EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.
</item>
    <item>HER2/NEU IMMUNOHISTOCHEMISTRY: EQUIVOCAL (2+) FOR OVEREXPRESSION
OF HER2/NEU ONCOPROTEIN.
</item>
    <item>HER2/NEU FISH RESULTS: NOT AMPLIFIED.</item>  </list>
</text>
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
Author
         
Source: PaLM Suppl. APSR 2.0-3:  6.3.6.2
Treetree.pnghl7:author
0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.png@typeCode
cs1 … 1FAUT
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor>
</author>
Treeblank.pngTreetree.pnghl7:templateId
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
Treeblank.pngTreetree.pnghl7:time
TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:assignedAuthor
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1
The author is either an assigned person or an authoring device.
Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
The name(s) SHALL be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 Example
represented organization for author as a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>
</representedOrganization>
Included0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)
The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPART
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
CS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treetree.pnghl7:entry
0 … 1CSource: PaLM Suppl. APSR 2.0-3: 6.2.5.4
         

Contains 1.3.6.1.4.1.19376.1.3.10.4.5 CDA Update Information Organizer (2017‑11‑14 15:22:14)
PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
Treeblank.png where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.4.5']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
 Constraintif ClinicalDocument.versionNumber > 1
Treetree.pnghl7:entry
1 … *MSource: PaLM Suppl. APSR 2.0-3: 6.2.5.2
         

Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (2015‑08‑13 10:24:55)
PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
Treeblank.png where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue

6.3.4.7 Procedure steps <section> - 1.3.6.1.4.1.19376.1.8.1.2.6

6.3.4.7.1 Definition and Purpose

The Procedure steps section contains the description of tissue sampling and dissection: representative specimens and derived specimens dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, electron microscopy, etc.) or biorepository. The only entry for this section is the Specimen Procedure Steps Entry module.

6.3.4.7.2 Specification and Example
Id1.3.6.1.4.1.19376.1.8.1.2.6Effective Date valid from 2014‑05‑13 19:33:12
StatusKyellow.png DraftVersion Label2.0
NameProcedureStepsSectionDisplay NameProcedure Steps Section
Description
The Procedure steps section contains the description of tissue dissection: representative specimens and derived specimens dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, electron microscopy, etc.) or biorepository.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.6
LabelPaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 2 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.1.1ContainmentKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example
Example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.6"/>  <code code="46059-2" codeSystem="2.16.840.1.113883.6.1" displayName="Special treatments and procedures section"/>  <title>PROCEDURE STEPS SECTION</title>  <text/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->
  <entry typeCode="COMP" contextConductionInd="false">
    <!-- template 1.3.6.1.4.1.19376.1.3.10.4.1 'Specimen Procedure Step' (2016-07-08T13:20:59) -->
  </entry>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … 1RPaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.png@moodCode
cs0 … 1FEVN
 Constraint

   This section SHALL contain a code element populated with these attributes:
   

@code ="46059-2"

@codeSystem ="2.16.840.1.113883.6.1"

@displayName ="Special treatments and procedures section" 

This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

The section SHOULD contain as many Specimen Procedure Steps entry elements as there are procedure steps or groups thereof to be described. These entries provide the machine-readable data corresponding to the narrative block. 

Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.6
Treetree.pnghl7:code
CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section
Treeblank.pngTreetree.png@code
CONF1 … 1F46059-2
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1FSpecial treatments and procedures section
Treetree.pnghl7:title
ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section
 CONF
element content shall be "PROCEDURE STEPS SECTION"
Treetree.pnghl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section
 Example
example for use case#1
<text>
   RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE
BIOPSY)
  <br/>  
PARAFFIN BLOCK NUMBER: A1.:FOUR SECTIONS FOR EACH STAIN:
  <br/>  <paragraph ID="A7102400008">RIGHT BREAST FIVE CORES 8-9:00</paragraph>  <paragraph ID="block_A_1">PARAFFIN BLOCK NUMBER: A1</paragraph>  <paragraph ID="slide_A_1_HE">slide from block A1 HE stained</paragraph>  <paragraph ID="slide_A_1_ER">slide from block A1 ER Immunohistochemistry</paragraph>  <paragraph ID="slide_A_1_PR">slide from block A1 PR Immunohistochemistry</paragraph>  <paragraph ID="slide_A_1_EGFR">slide from block A1 EGFR (PharmDX) Immunohistochemistry</paragraph>  <paragraph ID="slide_A_1_HER2">slide from block A1 HER2 Immunohistochemistry</paragraph>  <paragraph ID="slide_A_1_HER2_FISH">slide block from A1 HER2 FISH</paragraph></text>
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
Author

   
Source: PaLM Suppl.APSR 2.0‑3:6.3.6.2


Treetree.pnghl7:author
0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.png@typeCode
cs1 … 1FAUT
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor>
</author>
Treeblank.pngTreetree.pnghl7:templateId
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
Treeblank.pngTreetree.pnghl7:time
TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:assignedAuthor
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1
The author is either an assigned person or an authoring device.
Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
The name(s) SHALL be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 Example
represented organization for author as a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>
</representedOrganization>
Included0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)
The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPART
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
CS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treetree.pnghl7:entry
0 … *RSpecimen procedure steps 

Source: PaLM Suppl.APSR 2.0‑3:6.2.5.3
Contains 1.3.6.1.4.1.19376.1.3.10.4.1 Specimen Procedure Step (2016‑07‑08 13:20:59)
PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section
Treeblank.png where [@typeCode='COMP'] [hl7:procedure [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.4.1']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1 

6.3.5 CDA R2 <entry> Content Modules

6.3.5.1 Common Specification for all APSR Entry Content Modules

The unique <entry> Content Module available in all the sections except Procedure Steps <section> of the APSR template is the Problem Organizer <entry>.

The unique <entry> Content Module available in Procedure Steps <section> of the APSR template is Specimen Procedure Step <entry>.

Each <entry> Content Module carries machine-readable data related to one Problem on one specimen or on a group of specimens observed for this section.

Each <entry> Content Module is repeatable below its section, so as to support the use cases where a section reports on more than one specimen or more than one group of specimens.

6.3.5.2 Problem Organizer – 1.3.6.1.4.1.19376.1.8.1.3.6

6.3.5.2.1 Definition and purpose

This Content Module is usable as only <entry> within any Section module except Procedure steps <section>.

The problem organizer groups the battery of observations together with embedded images performed to investigate on a single problem identified on a specimen or group of specimens. If a Problem cannot be addressed specifically the Problem organizer allows also the grouping around one specimen.

6.3.5.2.2 Specification and Example
Id1.3.6.1.4.1.19376.1.8.1.3.6Effective Date valid from 2015‑08‑13 10:24:55
StatusKyellow.png DraftVersion Label2.0
NameProblemOrganizerDisplay NameProblem Organizer
Description
Template CDA Organizer (prototype, directly derived from POCD_RM000040 MIF)


The problem organizer groups the battery of observations performed to investigate on a single problem identified on a specimen or group of specimens. 

   
       
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.3.6
LabelPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 7 templates, Uses 11 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.3.10.3.1ContainmentKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.1ContainmentKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2ContainmentKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3ContainmentKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4ContainmentKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5ContainmentKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)2016‑07‑08 11:22:58
1.3.6.1.4.1.19376.1.8.1.4.7ContainmentKyellow.png Additional participant in an entry APSR (Body)2016‑07‑12 18:44:06
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.8.1.4.10ContainmentKyellow.png Embedded Image IHE2016‑06‑22 16:08:01
2.16.840.1.113883.10.12.307ContainmentKgreen.png CDA RegionOfInterest2005‑09‑07
1.3.6.1.4.1.19376.1.5.3.1.4.2ContainmentKgreen.png IHE Comment Entry (2014)2013‑12‑20
1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
1.3.6.1.4.1.19376.1.3.1.6ContainmentKgreen.png Laboratory Observation (2017)2008‑08‑08
2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA Reference2005‑09‑07
RelationshipSpecialization: template 2.16.840.1.113883.10.12.305 (2005‑09‑07)
Example
generated example
<organizer classCode="BATTERY" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.3.6"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">
    <qualifier>
      <name code="116677004" codeSystem="2.16.840.1.113883.6.96" displayName=" Associated topography (attribute)"/>      <value nullFlavor="cs" code="all children of "362981000"" codeSystem="2.16.840.1.113883.6.96" displayName="all values from 91723000 (Anatomical structure)"/>    </qualifier>
  </code>
  <component typeCode="COMP">
    <observation>
      <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">
        <value code="115597007" displayName="Description of specimen character (procedure)" codeSystem="2.16.840.1.113883.6.96"/>      </code>
    </observation>
  </component>
  <statusCode code="completed"/>  <effectiveTime>
    <low value="20170131165954"/>  </effectiveTime>
  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->
  </author>
  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->
  </informant>
  <participant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (2016-07-12T18:44:06) -->
  </participant>
  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->
  </performer>
  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 0..* R -->
  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (2016-06-22T16:08:01) -->
  </component>
  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' (2005-09-07T00:00:00) -->
  </component>
  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.4.2 'IHE Comment Entry' (2013-12-20T00:00:00) -->
  </component>
  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (2014-05-14T17:09:54) -->
  </component>
  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.3.1.6 'Laboratory Observation' (2008-08-08T00:00:00) -->
  </component>
  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
  </reference>
</organizer>
Example
example for use case #1, problem: invasive breast cancer
<organizer classCode="BATTERY" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.3.6"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_Problem1"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="201001041605-0500"/>  </effectiveTime>
  <!--The problem is expressed by the result of the observation having the same code as organizer/code-->
  <component>
    <observation classCode="OBS" moodCode="EVN">
      <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>      <value code="C50.9" codeSystem="2.16.840.1.113883.6.3" displayName="Malignant neoplasm of breast, unspecified" codeSystemDisplayName="ICD-10"/>    </observation>
  </component>
  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (2014-05-14T17:09:54) -->
  </component>
  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
  </reference>
</organizer>
ItemDTCardConfDescriptionLabel
hl7:organizer
0 … *RProblem organizer groups the battery of observations performed to investigate on a single problem identified on a specimen or a group of specimens. PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treetree.png@classCode
cs1 … 1FBATTERY
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.3.6
Treetree.pnghl7:id
II0 … *RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treetree.pnghl7:code
CD (required)0 … 1RProblem

PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.png@code
CONF0 … 1F75326-9
Treeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
0 … 1FLOINC
Treeblank.pngTreetree.png@displayName
0 … 1FProblem
Treetree.pnghl7:component
0 … 1RCoding of the Problem reportedPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.pnghl7:observation
0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CD (extensible)1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF0 … 1F75326-9
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
0 … 1FLOINC
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
0 … 1FProblem
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:qualifier
CR0 … *ROptional qualifier for separate problems with identical problem type in one specimen, e.g. a urothelial bladder cancer Invasive cancer) and a prostate cancer (invasive cancer) in one cystoprostatectomy specimen. The anatomic structure is able to differentiate.
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
 Example
Problem in urinary bladder in cystoprostatectomy specimen
<qualifier>
  <name code="116677004" codeSystem="2.16.840.1.113883.6.96" displayName="Associated topography (attribute)" codeSystemName="SNOMED-CT"/>  <value code="302512001" codeSystem="2.16.840.1.113883.6.96" displayName=" Entire urinary bladder (body structure)" codeSystemName="SNOMED-CT"/></qualifier>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
CV0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1F116677004
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F2.16.840.1.113883.6.96
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st1 … 1F Associated topography (attribute)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:value
CD (extensible)0 … *RPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF0 … 1F<< 91723000
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.6.96 (SNOMED Clinical Terms)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
0 … 1FSNOMED-CT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
0 … 1Fall values from Anatomical structure
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CE (extensible)0 … 1RCode of the problem reportedPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
 CONF
@code shall be "any_code"
@codeSystem shall be "2.16.840.1.113883.6.3"
@codeSystemName shall be "any_code"
@displayName shall be "ICD-10"
or
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.7 Problem Type (2016‑07‑11 09:52:19)
Treetree.pnghl7:statusCode
CS (required)1 … 1MPaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
 ConstraintThe status of the organizer is 

completed  if the battery of observations for this problem has been performed. It is  aborted  in case some of the intended observations could not be achieve and have been aborted, and appear as such below the organizer.


 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 (DYNAMIC)
Alert.pngError: Cannot find value set "1.3.6.1.4.1.19376.1.3.11.2"
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1MOrganizer time.

The period of time (possibly reduced to a point in time) during which the information was collected and assembled. 


PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treetree.pnghl7:author
0 … *CAuthor


Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2



Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.png where [hl7:author [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.2']]]
 ConstraintThe author SHALL be present if it is different from the main author of the report. For instance the author could be the ordering physician contributing to the Clinical Information section, inside a report authored by the pathologist.
Treetree.pnghl7:informant
0 … *RInformant


The informant is an actor (person and organization) who provided some of the clinical information carried by this organizer.

   
       


Source: PaLM Suppl. APSR 2.0-3:
    6.3.6.5

Contains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (2016‑07‑08 11:22:58)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.6']]
Treetree.pnghl7:participant
0 … *RTranscriptionist, Device, Responsible, Validator



Source: PaLM Suppl. APSR 2.0-3:  6.3.6.6



Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry APSR (Body) (2016‑07‑12 18:44:06)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.7']]
 ConstraintparticipationType "ENT", "DEV", "RESP", "AUTHEN"
Treetree.pnghl7:performer
0 … 1CPerforming lab.

The performing laboratory is present at this level only if this particular problem on this particular specimen was investigated by a (subcontractor) distinct laboratory from the one issuing the consolidated report

   
       
Source: 
PaLM TF-3: 6.3.2.20

Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
Included0 … *R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Specimen identification outside an AP observation for differentiating or restituting the problem type


Source: PaLM Suppl. APSR 2.0-3: 6.3.6.9


Treetree.pnghl7:specimen
0 … *RRequired in XD-LAB when more than one specimen is documented at this level. Always required in APSR.
PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreetree.png@typeCode
cs0 … 1FSPC
Treeblank.pngTreetree.pnghl7:specimenRole
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FSPEC
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treetree.pnghl7:component
0 … *REmbedded image


This organizer may carry an image focusing on the problem, either directly embedded or encapsulated within a region of interest.



Contains 1.3.6.1.4.1.19376.1.8.1.4.10 Embedded Image IHE (2016‑06‑22 16:08:01)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.png where [hl7:observationMedia [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.10']]]
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
 Constraint[@classCode="ROIOVL" and moodCode="EVN"]
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.pnghl7:seperatableInd
BL0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treetree.pnghl7:component
0 … *RRegion of interest


This organizer may carry an image focusing on the problem, either directly embedded or encapsulated within a region of interest.

   

In the latter case by an entryRelationship @typeCode="SUBJ"

   




Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (2005‑09‑07)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.png where [@typeCode='COMP'] [hl7:regionOfInterest [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.307']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
 Constraint[@classCode="ROIOVL" and moodCode="EVN"]
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.pnghl7:seperatableInd
BL0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treetree.pnghl7:component
0 … *RGeneral comment on this particular problem 



Source: PCC TF-2: 6.3.4.6
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.png where [@typeCode='COMP'] [hl7:act [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.20.1.40'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.2']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.pnghl7:seperatableInd
BL0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treetree.pnghl7:component
0 … *RAny kind of AP observation, for complex observations, e.g. for TNM, ICD-O-3, or Assessment scales, the appropriate templates may be used.


Source: PaLM Suppl. APSR 2.0-3: 6.3.6.7



Contains 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.png where [@typeCode='COMP'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.9']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.pnghl7:seperatableInd
BL0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treetree.pnghl7:component
0 … *CLaboratory observation
Contains 1.3.6.1.4.1.19376.1.3.1.6 Laboratory Observation (2008‑08‑08)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.png where [@typeCode='COMP'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.1.6']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treeblank.pngTreetree.pnghl7:seperatableInd
BL0 … 1PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer
Treetree.pnghl7:reference
0 … *RReference to an external document, or to external organizers, or to external observations, e.g. concerning molecular pathology or  genetic testing report

Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)
PaLM Suppl. 2.0‑3: 6.3.5.2 Problem organizer

6.3.5.3 Specimen Procedure Step <entry> - 1.3.6.1.4.1.19376.1.3.10.4.1

6.3.5.3.1 Definition and purpose

The Specimen Procedure Step <entry> Content Module contains in machine-readable form all the data concerning one specimen or a group of specimens together with its container(s). It is usable within a Procedure Steps <section> Content Module only. This Content Module structures the machine-readable data, which characterize the specimens and the procedures of their collection and processing (identifiers and types, time intervals, performers, target site).
By referencing the child procedure ID via an entryRelationship the entry is used in an iterative manner for each single step of specimen collection and processing, which results in derived (child) specimen.
The resulting specimen is the participant in the procedure according to the CDA-RIM (fig. 6.2.5.3.2-1) with the typeCode="PRD", and the role of "SPEC". The specimen ID is the ParticipantRole.ID.
Additives (e.g. fixatives) MAY be additional participants with the typeCode="CSM".
Each specimen is put in or on an appropriate container. The container is described through an EntryRelationship to a Supply whose product is the container (see this volume, 6.3.6.4).
The specimen reception in laboratory may be expressed through another EntryRelationship of typeCode "COMP", introducing the "specimen received" Act.
In case the procedure step produces a child specimen, the parent specimen is the specimen on which the procedure is performed. Thus the parent specimen is represented by a Specimen participation to the procedure. In this case, Specimen.SpecimenRole.Id is the id of the parent specimen. These parent specimens might be multiple, for instance in the case of TMA.Therefore, cardinalities of Specimen are [0..*]
Specimen and their containers carry IDs as well as further attributes, which are defined in the HL7 Specimen DAM.

HL7 DAM Specimen Release 1.


6.2.6.4.1-1 container 5.jpg

Figure 6.3.5.3.1-1 CDA-RMIM of the Specimen Procedure Steps <entry>

According to the CDA RIM in the Content Module further supporting Content Modules for Participant, and Playing Entity are needed, which have the (preliminary) OIDs 1.3.6.1.4.1.19376.1.3.10.9.20, 1.3.6.1.4.1.19376.1.3.10.9.21). The

The Code systems and Value sets MAY be organized organ-specific.

6.3.5.3.2 Specification and Example
Id1.3.6.1.4.1.19376.1.3.10.4.1Effective Date valid from 2016‑07‑08 13:20:59

There are versions of templates with this id:
  • SpecimenProcedureStep as of 2016‑07‑08 13:20:59
  • SpecimenProcedureStep as of 2014‑07‑29 16:02:02
StatusKyellow.png DraftVersion Label2.0
NameSpecimenProcedureStepDisplay NameSpecimen Procedure Step
Description
Template CDA Procedure (prototype, directly derived from 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.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.1
LabelPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 4 templates, Uses 8 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.8.1.2.6Link.pngKyellow.png Procedure Steps Section (2.0)2014‑05‑13 19:33:12
1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.3.10.9.44ContainmentKyellow.png CDA Participant (Body) Procedure Steps APSR2 (2.0)2014‑10‑26 17:06:28
1.3.6.1.4.1.19376.1.3.10.9.22ContainmentKyellow.png CDA Supply Container APSR2 (2.0)2016‑07‑29 12:09:33
1.3.6.1.4.1.19376.1.3.1.3ContainmentKgreen.png Specimen Received (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA Reference2005‑09‑07
RelationshipAdaptation: template 2.16.840.1.113883.10.12.306 (2005‑09‑07)
Example
generated example
<procedure negationInd="false" classCode="PROC" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.4.1"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="117617002" displayName="Immunohistochemistry procedure (procedure)" codeSystem="2.16.840.1.113883.5.96">
    <qualifier>
      <name code="246094008 or 246355002" codeSystem="2.16.840.1.113883.6.96" displayName="Component investigated (attribute) or Supporting structure (attribute)"/>      <value code="23307004" codeSystem="2.16.840.1.113883.6.96" displayName="Estrogen receptor (substance)"/>    </qualifier>
  </code>
  <text/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20161110104817"/>  </effectiveTime>
  <targetSiteCode code="441652008" codeSystem="2.16.840.1.113883.6.96" displayName="Formalin-fixed paraffin-embedded tissue specimen (specimen)"/>  <specimen typeCode="SPC">
    <specimenRole classCode="SPEC">
      <id/>    </specimenRole>
  </specimen>
  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->
  </performer>
  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->
  </author>
  <participant>
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.44 'CDA Participant (Body) Procedure Steps APSR2' (2014-10-26T17:06:28) -->
  </participant>
  <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">
    <seperatableInd value="false"/>    <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.22 'CDA Supply Container APSR2' (2016-07-29T12:09:33) -->
  </entryRelationship>
  <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">
    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.3.1.3 'Specimen Received' (2008-08-08T00:00:00) -->
  </entryRelationship>
  <entryRelationship negationInd="false" typeCode="REFR" inversionInd="false" contextConductionInd="true">
    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.4.1 'Specimen Procedure Step' (2016-07-08T13:20:59) -->
  </entryRelationship>
  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
  </reference>
</procedure>
ItemDTCardConfDescriptionLabel
hl7:procedure
0 … *RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treetree.png@classCode
cs1 … 1FPROC
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.4.1
Treetree.pnghl7:id
II0 … *RProcedure ID, coming from the LIS.
May be the target (referenced) ID for the child procedure.
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treetree.pnghl7:code
CD (extensible)1 … 1MCoded procedurePaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 Constraintfor specimen collection procedure codes for targetSite 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
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.10 Specimen Collection and Processing (2016‑05‑31 15:09:59)
 Example
for use case #1, specimen collection
<code code="122548005" codeSystem="2.16.840.1.113883.6.96" displayName="Biopsy of breast (procedure)" codeSystemName="SNOMED-CT"/>
 Example
for use case #1, grossing & embedding
<code code="40923002" codeSystem="2.16.840.1.113883.6.96" displayName="Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)"/>
 Example
for use case #1, sectioning & immunostaining
<code code="117617002" codeSystem="2.16.840.1.113883.6.96" displayName="Immunohistochemistry procedure (procedure)"/>
Treeblank.pngTreetree.pnghl7:qualifier
CR (extensible)0 … *CQualifier for staining or other procedures which don´t have values in the vocabulary used.
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 ConstraintUsed only in staining and other procedures without values in SCT or LOINC or DICOM vocabulary, e.g. immune stains
 Example
for use case #1, grossing & embedding
<qualifier>
  <name code="246355002" displayName="Supporting structure (attribute)" codeSystem="2.16.840.1.113883.6.96"/>  <value code="702941008" displayName="Paraffin embedding (qualifier value)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/></qualifier>
 Example
for use case #1, Estrogen receptor staining
<qualifier>
  <name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/>  <value code="23307004" displayName="Estrogen receptor (substance)" codeSystem="2.16.840.1.113883.6.96"/></qualifier>
 Example
for use case #1, ISH Her-2-neu staining
<qualifier>
  <name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/>  <value code="164870" displayName="ONCOGENE ERBB2" codeSystem="2.16.840.1.113883.6.174" codeSystemName="OMIM"/></qualifier>
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV (extensible)1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs0 … 1F246094008_or_246355002
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid0 … 1F2.16.840.1.113883.6.96
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st0 … 1FComponent investigated (attribute) or Supporting structure (attribute)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD (extensible)1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs1 … 1R
 CONF
@code shall be "<<105590001 | Substance (substance) |"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SNOMED-CT"
@displayName shall be "values from substance axis, e.g. Estrogen receptor"
or
@code shall be "values from G axis"
@codeSystem shall be "2.16.840.1.113883.6.174"
@codeSystemName shall be "OMIM"
@displayName shall be "values from G axis, e.g. erb-b2"
or
@code shall be "<<272394005 | Technique (qualifier value) |"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SNOMED-CT"
@displayName shall be "values from technique axis, e.g. Paraffin embedded (qualifier)"
Treetree.pnghl7:text
ED0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 Example
specimen collection procedure
<text>ULTRASOUND GUIDED NEEDLE CORE BIOPSY</text>
 Example
specimen processing procedure
<text>CUTTING A SLIDE FROM A PARAFFIN BLOCK</text>
Treetree.pnghl7:statusCode
CS (required)0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS0 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treetree.pnghl7:approachSiteCode
CD (extensible)0 … 1RApproach site in specimen collectionPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreetree.png@code
CONF0 … 1Fany_code
Treeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.5.1052 (Act Site)
Treeblank.pngTreetree.png@codeSystemName
0 … 1Fany_code
Treeblank.pngTreetree.png@displayName
0 … 1FActSite
Treetree.pnghl7:target​Site​Code
CD (extensible)0 … 1RTarget site in body or relative parent relationship in case of  specimen processingPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 CONF
@code shall be "<<123037004 | Body structure (body structure) |"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SCT"
@displayName shall be "all children of Body structure (body structure)"
or
@code shall be "any_code"
@codeSystem shall be "2.16.840.1.113883.5.1052"
@codeSystemName shall be "ActSite"
@displayName shall be "any_code"
or
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.9 Procedure Site (2016‑06‑01 18:46:15)
 Example
for use case #1, specimen collection
<targetSiteCode code="110497008" displayName="Lower outer quadrant of right breast (body structure)" codeSystem="2.16.840.1.113883.6.96"/>
 Example
for use case #1, grossing & embedding
<targetSiteCode code="309050000" displayName="Body substance sample" codeSystem="2.16.840.1.113883.6.96"/>
Treeblank.pngTreetree.pnghl7:qualifier
CR (extensible)0 … *Coptional qualifiers for specifying body structures or / and lateralityPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
 Example
for use case #1, (optional) specification of body structure for specimen collection
<qualifier>
  <name code="118169006" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen source topography (attribute)" codeSystemName="SNOMED-CT"/>  <value code="255495000" codeSystem="2.16.840.1.113883.6.96" displayName="Right lower quadrant (qualifier value)" codeSystemName="SNOMED-CT"/></qualifier>
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV (extensible)1 … 1RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st0 … 1FSpecimen source topography
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F2.16.840.1.113883.6.96
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1F118169006
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD (extensible)0 … *RPaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF0 … 1 @code shall be out of choice:
  • <<272099008
  • Descriptor (qualifier value)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.6.96 (SNOMED Clinical Terms)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
0 … 1FSCT
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
0 … 1Fall children of "Descriptor, qualifier values", e.g. right lower quadrantt
Treetree.pnghl7:methodCode
CD (extensible)0 … *RIdentifies the technique used to perform a procedure
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.pngTreetree.png@codeSystem
cs1 … 1F2.16.840.1.113883.5.1065
Included0 … 1R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Parent specimen with parent ID
 Example
for use case #1, parent specimen ID in grossing & embedding
<specimen typeCode="SPC">
  <specimenRole classCode="SPEC">
    <!-- Parent specimen ID -->
    <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008"/>  </specimenRole>
</specimen>
Treetree.pnghl7:specimen
0 … 1RRequired in XD-LAB when more than one specimen is documented at this level. Always required in APSR.
PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreetree.png@typeCode
cs0 … 1FSPC
Treeblank.pngTreetree.pnghl7:specimenRole
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FSPEC
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treetree.pnghl7:performer
0 … 1RContains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
Treetree.pnghl7:author
0 … *CContains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.png where [hl7:author [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.2']]]
Treetree.pnghl7:participant
1 … *MOne or more specimen (with additives), which participates as product of the procedure
Contains 1.3.6.1.4.1.19376.1.3.10.9.44 CDA Participant (Body) Procedure Steps APSR2 (2014‑10‑26 17:06:28)
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.png where [not(@nullFlavor)]
Treetree.pnghl7:entryRelationship
0 … *RArtificial material (manufactured product) which
   containes 
the specimen
Contains 1.3.6.1.4.1.19376.1.3.10.9.22 CDA Supply Container APSR2 (2016‑07‑29 12:09:33)
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.png where [@typeCode='COMP'] [hl7:supply [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.22']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
 Constraintfor manufactured product


classCode = MANU

for DrugOrOtherMaterial
classCode = MMAT
code from MaterialEntityClassType


Treetree.pnghl7:entryRelationship
0 … 1RSpecimen arrival in Lab
Contains 1.3.6.1.4.1.19376.1.3.1.3 Specimen Received (2008‑08‑08)
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.png where [@typeCode='COMP'] [hl7:act [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.1.3']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:entryRelationship
0 … *RReferencing mechanism to the ID of the child procedures, giving a lis of child procedure IDs
Contains 1.3.6.1.4.1.19376.1.3.10.4.1 Specimen Procedure Step (2016‑07‑08 13:20:59)
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps
Treeblank.png where [@typeCode='REFR'] [hl7:procedure [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.4.1']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFR
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
 Constraintcontains only ID of the child procedure, which is fully described in a dedicated entry further down in the Procedure step section.
Treetree.pnghl7:reference
0 … *RReference to an external document, or to external procedures, e.g. concerning molecular pathology or  genetic testing report

Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)
PaLM Suppl. 2.0‑3: 6.3.5.3 Specimen procedure steps

6.3.6 CDA R2 Child Element Content Modules

This section specifies the Content Modules designed for child elements. A child element is a child of the CDA header or a child of a <section>, or an element nested at various depths below an <entry>, or an element appearing at some combination of these locations.

6.3.6.1 Specimen Collector in Header – 1.3.6.1.4.1.19376.1.8.1.4.1

6.3.6.1.1 Definition and purpose

This Content Module is usable only in the CDA header.

This Content Module is used only in the situation where the specimen was not collected by the ordering physician. (See use cases in volume 1)

6.3.6.1.2 Specification and Example
Id1.3.6.1.4.1.19376.1.8.1.4.1Effective Date valid from 2016‑06‑13 14:21:13
StatusKyellow.png DraftVersion Label
NameCDAParticipantSpecimenCollectorDisplay NameCDA Participant Specimen Collector
Description
Template CDA participant (prototype, directly derived from POCD_RM000040 MIF)


This Content Module is usable only in the CDA header. 

This Content Module is used only in the situation where the specimen was not collected by the ordering physician.

   
       


LabelPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 2 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.1.1IncludeKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
2.16.840.1.113883.10.12.152ContainmentKgreen.png CDA Person2005‑09‑07
2.16.840.1.113883.10.12.151ContainmentKgreen.png CDA Organization2005‑09‑07
RelationshipSpecialization: template 2.16.840.1.113883.10.12.108 (2005‑09‑07)
Example
generated example
<participant typeCode="DIST" contextControlCode="OP">
  <templateID root="1.3.6.1.4.1.19376.1.8.1.4.1"/>  <time>
    <low value="20170127121035"/>  </time>
  <associatedEntity classCode="PROV">
    <id root="1.2.3.999" extension="--example only--"/>    <code code="--code--" codeSystem="2.16.840.1.113883.5.111"/>    <addr>addr</addr>    <telecom/>    <associatedPerson>
      <!-- template 2.16.840.1.113883.10.12.152 'CDA Person' (dynamic) -->
    </associatedPerson>
    <scopingOrganization>
      <!-- template 2.16.840.1.113883.10.12.151 'CDA Organization' (dynamic) -->
    </scopingOrganization>
  </associatedEntity>
</participant>
ItemDTCardConfDescriptionLabel
hl7:participant
0 … *RThe Specimen Collector Content Module is only used in case a specimen provided as input to the AP act documented in this report, was collected by a different party than the ordering physician. In that case, this specimen collector is represented in the CDA header as a participant element with the typeCode attribute valued “DIST” and the sub-element participant/time carries the time period of the specimen collection.
PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treetree.png@typeCode
cs1 … 1FDIST
Treetree.pnghl7:templateID
II1 … 1MPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.1
Treetree.pnghl7:time
IVL_TS1 … 1MSpecimen collection time


The specimen collection time is an interval, which may be reduced to a point in time (see usage of data type IVL_TS).

   
       
PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treetree.pnghl7:associated​Entity
0 … 1RAt least one of the two elements

associatedPerson and scopingOrganization must be present. Both may be present.  

   
       
PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreetree.png@classCode
cs1 … 1FPROV
Treeblank.pngTreetree.pnghl7:id
II1 … *RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreetree.pnghl7:addr
AD1 … *RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreetree.pnghl7:telecom
TEL.AT1 … *RPaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreetree.pnghl7:associated​Person
0 … *CPerson who collected the specimen.
Only full name(s) SHALL be given.
Contains 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector
Treeblank.pngTreetree.pnghl7:scoping​Organization
0 … 1COrganization taking care for specimen collection.
Identifiers, name, telecom, and address SHOULD be given.
Contains 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)
PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector

6.3.6.2 Author – 1.3.6.1.4.1.19376.1.8.1.4.2

6.3.6.2.1 Definition and purpose

This Content Module is usable in the CDA header, in a <section> and at various depths of an <entry>.

It describes an author having contributed to the document wholly or to a portion of it (e.g., a section, an observation, a group of observations).

A given document or any delimited portion of it may have more than one author.

An author MAY be a person or a device (manufactured device or software system). In both cases the scoping organization MAY be described.

6.3.6.2.2 Specification and Example
Id1.3.6.1.4.1.19376.1.8.1.4.2Effective Date valid from 2016‑06‑21 14:02:11
StatusKyellow.png DraftVersion Label
NameCDAAuthorIHEDisplay NameCDA author IHE
Description
Template CDA author (prototype, directly derived from POCD_RM000040 MIF).
   
   
This Content Module is usable in the CDA header, in a <section> and at various depths of an <entry>.

It describes an author having contributed to the document wholly or to a portion of it (e.g., a section, an observation, a group of observations).

   
A given document or any delimited portion of it may have more than one author.

An author MAY be a person or a device (manufactured device or software system). In both cases the scoping organization MAY be described.
LabelPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 34 templates, Uses 2 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.3.10.3.1IncludeKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.1IncludeKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2IncludeKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3IncludeKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4IncludeKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5IncludeKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.2.6IncludeKyellow.png Procedure Steps Section (2.0)2014‑05‑13 19:33:12
1.3.6.1.4.1.19376.1.8.1.2.7IncludeKcancelledblue.png Report Textual Summary Section (2.0)2016‑06‑13 17:54:42
1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.3.10.4.2ContainmentKyellow.png TNM Stage Observation (2.0)2014‑05‑13 15:45:13
1.3.6.1.4.1.19376.1.3.10.4.3ContainmentKyellow.png ICD-O-3 Typing and Grading Observation (2.0)2015‑11‑29 17:03:18
1.3.6.1.4.1.19376.1.3.10.4.4ContainmentKyellow.png Assessment Scales Observation for Scoring Systems APSR2 (2.0)2016‑10‑06 13:12:00
1.3.6.1.4.1.19376.1.3.10.4.5ContainmentKyellow.png CDA Update Information Organizer (2.0)2017‑11‑14 15:22:14
1.3.6.1.4.1.19376.1.3.10.9.22ContainmentKyellow.png CDA Supply Container APSR2 (2.0)2016‑07‑29 12:09:33
1.3.6.1.4.1.19376.1.3.10.9.25ContainmentKyellow.png TNM T-Observation (2.0)2014‑12‑02 15:54:17
1.3.6.1.4.1.19376.1.3.10.9.26ContainmentKyellow.png TNM N-Observation (2.0)2014‑12‑02 16:34:50
1.3.6.1.4.1.19376.1.3.10.9.27ContainmentKyellow.png TNM M-Observation (2.0)2014‑12‑02 16:32:30
1.3.6.1.4.1.19376.1.3.10.9.28ContainmentKyellow.png TNM Grading (2.0)2015‑11‑15 13:01:18
1.3.6.1.4.1.19376.1.3.10.9.29ContainmentKyellow.png TNM R-status (2.0)2015‑06‑30 13:38:30
1.3.6.1.4.1.19376.1.3.10.9.30ContainmentKyellow.png TNM a (2.0)2015‑06‑22 15:13:46
1.3.6.1.4.1.19376.1.3.10.9.31ContainmentKyellow.png TNM r (2.0)2015‑06‑22 17:38:42
1.3.6.1.4.1.19376.1.3.10.9.32ContainmentKyellow.png TNM y (2.0)2015‑06‑22 17:28:17
1.3.6.1.4.1.19376.1.3.10.9.33ContainmentKyellow.png TNM Serum tumor markers (2.0)2015‑11‑06 14:28:44
1.3.6.1.4.1.19376.1.3.10.9.34ContainmentKyellow.png TNM Lymphatic Invasion (2.0)2015‑11‑16 14:01:58
1.3.6.1.4.1.19376.1.3.10.9.35ContainmentKyellow.png TNM Venous Invasion (2.0)2015‑11‑16 13:40:28
1.3.6.1.4.1.19376.1.3.10.9.36ContainmentKyellow.png TNM Perineural Invasion (2.0)2015‑11‑11 16:13:40
1.3.6.1.4.1.19376.1.3.10.9.37ContainmentKyellow.png TNM Number of nodes (2.0)2014‑12‑02 16:48:36
1.3.6.1.4.1.19376.1.3.10.9.43ContainmentKyellow.png Assessment Scoring Item APSR 2.0 (2.0)2016‑10‑11 10:26:17
1.3.6.1.4.1.19376.1.3.10.9.42Link.pngKyellow.png Assessment Scoring System APSR 2.0 (2.0)2016‑10‑10 11:33:36
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.8.1.4.10ContainmentKyellow.png Embedded Image IHE2016‑06‑22 16:08:01
1.3.6.1.4.1.19376.1.8.1.4.9Link.pngKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
Uses as NameVersion
2.16.840.1.113883.10.12.152IncludeKgreen.png CDA Person2005‑09‑07
2.16.840.1.113883.10.12.151IncludeKgreen.png CDA Organization2005‑09‑07
RelationshipAdaptation: template 2.16.840.1.113883.10.12.102 (DYNAMIC)
Example
author is a person
<author typeCode="AUT">
  <functionCode code="DISPHYS" displayName="discharging physician" codeSystem="2.16.840.1.113883.5.88" codeSystemName="ParticipationFunction"/>  <time value="20130407130000+0500"/>  <assignedAuthor classCode="ASSIGNED">
    <assignedPerson classCode="PSN" determinerCode="INSTANCE">
      <name>
        <given>Marie</given>        <family>Müller</family>      </name>
    </assignedPerson>
    <representedOrganization>
      <id root="2.16.840.1.113883.19.5"/>      <name>Beispiel Krankenhaus</name>    </representedOrganization>
  </assignedAuthor>
</author>
Example
author is a device
<author typeCode="AUT">
  <assignedAuthor classCode="ASSIGNED">
    <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
      <code>...</code>    </assignedAuthoringDevice>
  </assignedAuthor>
</author>
ItemDTCardConfDescriptionLabel
hl7:author
0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treetree.png@typeCode
cs1 … 1FAUT
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor>
</author>
Treetree.pnghl7:templateId
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
Treetree.pnghl7:time
TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treetree.pnghl7:assignedAuthor
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreetree.pnghl7:id
II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:addr
AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:telecom
TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1
The author is either an assigned person or an authoring device.
Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
The name(s) SHALL be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:represented​Organization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 Example
represented organization for author as a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>
</representedOrganization>
Included0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)
The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given.
Treeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPART
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
CS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

6.3.6.3 Content Validator – 1.3.6.1.4.1.19376.1.8.1.4.3

6.3.6.3.1 Definition and purpose

This Content Module is usable only in the CDA header.

It describes a pathologist having verified the content of the report, using the element authenticator. This element authenticator is used when the pathologist having verified the content of the report is distinct from the pathologist assuming the legal responsibility for this report, described in the legalAuthenticator element.

The report MAY have zero or more Content Validators.

6.3.6.3.2 Specification and Example
Id1.3.6.1.4.1.19376.1.8.1.4.2Effective Date valid from 2016‑06‑21 14:02:11
StatusKyellow.png DraftVersion Label
NameCDAAuthorIHEDisplay NameCDA author IHE
Description
Template CDA author (prototype, directly derived from POCD_RM000040 MIF).
   
   
This Content Module is usable in the CDA header, in a <section> and at various depths of an <entry>.

It describes an author having contributed to the document wholly or to a portion of it (e.g., a section, an observation, a group of observations).

   
A given document or any delimited portion of it may have more than one author.

An author MAY be a person or a device (manufactured device or software system). In both cases the scoping organization MAY be described.
LabelPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
ClassificationCDA Header Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 34 templates, Uses 2 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.3.10.3.1IncludeKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.1IncludeKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2IncludeKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3IncludeKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4IncludeKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5IncludeKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.2.6IncludeKyellow.png Procedure Steps Section (2.0)2014‑05‑13 19:33:12
1.3.6.1.4.1.19376.1.8.1.2.7IncludeKcancelledblue.png Report Textual Summary Section (2.0)2016‑06‑13 17:54:42
1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.3.10.4.2ContainmentKyellow.png TNM Stage Observation (2.0)2014‑05‑13 15:45:13
1.3.6.1.4.1.19376.1.3.10.4.3ContainmentKyellow.png ICD-O-3 Typing and Grading Observation (2.0)2015‑11‑29 17:03:18
1.3.6.1.4.1.19376.1.3.10.4.4ContainmentKyellow.png Assessment Scales Observation for Scoring Systems APSR2 (2.0)2016‑10‑06 13:12:00
1.3.6.1.4.1.19376.1.3.10.4.5ContainmentKyellow.png CDA Update Information Organizer (2.0)2017‑11‑14 15:22:14
1.3.6.1.4.1.19376.1.3.10.9.22ContainmentKyellow.png CDA Supply Container APSR2 (2.0)2016‑07‑29 12:09:33
1.3.6.1.4.1.19376.1.3.10.9.25ContainmentKyellow.png TNM T-Observation (2.0)2014‑12‑02 15:54:17
1.3.6.1.4.1.19376.1.3.10.9.26ContainmentKyellow.png TNM N-Observation (2.0)2014‑12‑02 16:34:50
1.3.6.1.4.1.19376.1.3.10.9.27ContainmentKyellow.png TNM M-Observation (2.0)2014‑12‑02 16:32:30
1.3.6.1.4.1.19376.1.3.10.9.28ContainmentKyellow.png TNM Grading (2.0)2015‑11‑15 13:01:18
1.3.6.1.4.1.19376.1.3.10.9.29ContainmentKyellow.png TNM R-status (2.0)2015‑06‑30 13:38:30
1.3.6.1.4.1.19376.1.3.10.9.30ContainmentKyellow.png TNM a (2.0)2015‑06‑22 15:13:46
1.3.6.1.4.1.19376.1.3.10.9.31ContainmentKyellow.png TNM r (2.0)2015‑06‑22 17:38:42
1.3.6.1.4.1.19376.1.3.10.9.32ContainmentKyellow.png TNM y (2.0)2015‑06‑22 17:28:17
1.3.6.1.4.1.19376.1.3.10.9.33ContainmentKyellow.png TNM Serum tumor markers (2.0)2015‑11‑06 14:28:44
1.3.6.1.4.1.19376.1.3.10.9.34ContainmentKyellow.png TNM Lymphatic Invasion (2.0)2015‑11‑16 14:01:58
1.3.6.1.4.1.19376.1.3.10.9.35ContainmentKyellow.png TNM Venous Invasion (2.0)2015‑11‑16 13:40:28
1.3.6.1.4.1.19376.1.3.10.9.36ContainmentKyellow.png TNM Perineural Invasion (2.0)2015‑11‑11 16:13:40
1.3.6.1.4.1.19376.1.3.10.9.37ContainmentKyellow.png TNM Number of nodes (2.0)2014‑12‑02 16:48:36
1.3.6.1.4.1.19376.1.3.10.9.43ContainmentKyellow.png Assessment Scoring Item APSR 2.0 (2.0)2016‑10‑11 10:26:17
1.3.6.1.4.1.19376.1.3.10.9.42Link.pngKyellow.png Assessment Scoring System APSR 2.0 (2.0)2016‑10‑10 11:33:36
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.8.1.4.10ContainmentKyellow.png Embedded Image IHE2016‑06‑22 16:08:01
1.3.6.1.4.1.19376.1.8.1.4.9Link.pngKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
Uses as NameVersion
2.16.840.1.113883.10.12.152IncludeKgreen.png CDA Person2005‑09‑07
2.16.840.1.113883.10.12.151IncludeKgreen.png CDA Organization2005‑09‑07
RelationshipAdaptation: template 2.16.840.1.113883.10.12.102 (DYNAMIC)
Example
author is a person
<author typeCode="AUT">
  <functionCode code="DISPHYS" displayName="discharging physician" codeSystem="2.16.840.1.113883.5.88" codeSystemName="ParticipationFunction"/>  <time value="20130407130000+0500"/>  <assignedAuthor classCode="ASSIGNED">
    <assignedPerson classCode="PSN" determinerCode="INSTANCE">
      <name>
        <given>Marie</given>        <family>Müller</family>      </name>
    </assignedPerson>
    <representedOrganization>
      <id root="2.16.840.1.113883.19.5"/>      <name>Beispiel Krankenhaus</name>    </representedOrganization>
  </assignedAuthor>
</author>
Example
author is a device
<author typeCode="AUT">
  <assignedAuthor classCode="ASSIGNED">
    <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
      <code>...</code>    </assignedAuthoringDevice>
  </assignedAuthor>
</author>
ItemDTCardConfDescriptionLabel
hl7:author
0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treetree.png@typeCode
cs1 … 1FAUT
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor>
</author>
Treetree.pnghl7:templateId
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
Treetree.pnghl7:time
TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treetree.pnghl7:assignedAuthor
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreetree.pnghl7:id
II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:addr
AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:telecom
TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 1
The author is either an assigned person or an authoring device.
Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
The name(s) SHALL be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreetree.pnghl7:represented​Organization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 Example
represented organization for author as a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>
</representedOrganization>
Included0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)
The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given.
Treeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPART
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
CS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author

6.3.6.4 Specimen Container in Specimen Procedure Step - 1.3.6.1.4.1.19376.1.3.10.9.22

6.3.6.4.1 Definition and purpose

This Supporting Content Module is usable in the Specimen Procedure Steps <entry> (see 6.2.6.4). It describes the properties of containers, in or on which the specimens are processed. The relations between container and specimen are described in the HL7 Specimen DAM.

HL7 DAM Specimen Release 1.

For Anatomic Pathology the CDA Content Modules "Material" and "ManufacturedMaterial" were modified under the (preliminary) OIDs 1.3.6.1.4.1.19376.1.3.10.9.23 and 1.3.6.1.4.1.19376.1.3.10.9.24

6.3.6.4.2 Specification and Example
Id1.3.6.1.4.1.19376.1.3.10.9.22Effective Date valid from 2016‑07‑29 12:09:33
StatusKyellow.png DraftVersion Label2.0
NameCDASupplyContainerAPSR2Display NameCDA Supply Container APSR2
Description
Template CDA Supply (prototype, directly derived from POCD_RM000040 MIF)

This entry describes the properties of a container (and its components) which holds a specimen. It is usable within a Specimen Procedure Step entry and is repeatable in one procedure step for describing container components, too (e.g. container plus embedding medium, or microscopic slide plus mounting medium plus coverslip)
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.22
LabelPaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 4 templates, Uses 6 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.8.1.2.6Link.pngKyellow.png Procedure Steps Section (2.0)2014‑05‑13 19:33:12
1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.3.10.9.24ContainmentKyellow.png CDA ManufacturedProduct APSR22016‑09‑09 12:37:49
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)2016‑07‑08 11:22:58
2.16.840.1.113883.10.12.300ContainmentKgreen.png CDA Clinical Statement2005‑09‑07
RelationshipSpecialization: template 2.16.840.1.113883.10.12.309 (2005‑09‑07)
Example
example for use case #1, grossing and embedding
<supply classCode="SPLY" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.9.22"/>  <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_block_A_1-C"/>  <code code="74384-9" codeSystem="2.16.840.1.113883.6.1" displayName="Specimen container"/>  <text/>  <statusCode code="completed"/>  <effectiveTime/>  <priorityCode/>  <repeatNumber/>  <independentInd value="false"/>  <quantity value="1"/>  <expectedUseTime>
    <low value="201001030905-0500"/>  </expectedUseTime>
  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 0..* O
ID of the specimen linked to the container -->
  <specimen typeCode="SPC">
    <specimenRole classCode="SPEC">
      <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_block_A_1"/>    </specimenRole>
  </specimen>
  <product typeCode="PRD">
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.24 'CDA ManufacturedProduct APSR2' (2016-09-09T12:37:49) -->
  </product>
  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->
  </performer>
  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->
  </author>
  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->
  </informant>
  <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">
    <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 2.16.840.1.113883.10.12.300 'CDA Clinical Statement' (2005-09-07T00:00:00) -->
  </entryRelationship>
</supply>
ItemDTCardConfDescriptionLabel
hl7:supply
0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
Treetree.png@classCode
cs1 … 1FSPLY
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.9.22
Treetree.pnghl7:id
II0 … *RContainer ID, coming from the LIS
PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
Treetree.pnghl7:code
CD0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
Treeblank.pngTreetree.png@code
CONF0 … 1F74384-9
Treeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
0 … 1FLOINC
Treeblank.pngTreetree.png@displayName
0 … 1FSpecimen container
Treetree.pnghl7:text
ED0 … 1RTextual description of the container (plus container components)PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
 Example
plastic tube
<text>plastic tube</text>
 Example
Block
<text>paraffin block</text>
 Example
Slide
<text>slide with mounting medium and coverslip</text>
Treetree.pnghl7:statusCode
CS (required)1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (2014‑03‑26)
Treetree.pnghl7:effectiveTime
SXCM_TS0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
Treetree.pnghl7:quantity
PQ0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
Treetree.pnghl7:expectedUseTime
IVL_TS0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
Included0 … *R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Treetree.pnghl7:specimen
0 … *RRequired in XD-LAB when more than one specimen is documented at this level. Always required in APSR.
PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreetree.png@typeCode
cs0 … 1FSPC
Treeblank.pngTreetree.pnghl7:specimenRole
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FSPEC
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treetree.pnghl7:product
1 … 1MContains 1.3.6.1.4.1.19376.1.3.10.9.24 CDA ManufacturedProduct APSR2 (2016‑09‑09 12:37:49)PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
Treeblank.png where [@typeCode='PRD'] [not(@nullFlavor)]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FPRD
Treetree.pnghl7:performer
0 … *CContains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
Treetree.pnghl7:author
0 … *CContains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
Treeblank.png where [hl7:author [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.2']]]
Treetree.pnghl7:informant
0 … *RContains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (2016‑07‑08 11:22:58)PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.6']]
Treetree.pnghl7:entryRelationship
0 … *RContains 2.16.840.1.113883.10.12.300 CDA Clinical Statement (2005‑09‑07)PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
Treeblank.png where [@typeCode='COMP'] [hl7:act [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.301']] or
[hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.302']] or
[hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.303']] or
[hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.304']] or
[hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.305']] or
[hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.306']] or
[hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.307']] or
[hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.308']] or
[hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.309']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treeblank.pngTreetree.png@inversionInd
bl0 … 1 
Treeblank.pngTreetree.png@negationInd
bl0 … 1 
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container
Treeblank.pngTreetree.pnghl7:seperatableInd
BL0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.6.4 Specimen container

6.3.6.5 Informant – 1.3.6.1.4.1.19376.1.8.1.4.6

6.3.6.5.1 Definition and purpose

This Content Module is usable in the CDA header, in a <section> and within an <entry>.

It describes a person having provided some piece of relevant information for the document.

A <ClinicalDocument> or a <section> or any kind of act below an <entry>, MAY have zero or more informant.

6.3.6.5.2 Specification and Example
Id1.3.6.1.4.1.19376.1.8.1.4.6Effective Date valid from 2016‑07‑08 11:22:58
StatusKyellow.png DraftVersion Label2.0
NameCDAinformantHeaderBodyAPSR2Display NameCDA Informant(Header&Body) APSR2
Description
Template CDA Informant Body (prototype, directly derived from POCD_RM000040 MIF)

   
An informant is either an assignedEntity (a professional participating to the healthcare process, and who was assigned a defined role in that process) or a relatedEntity (a person who knows the patient and has provided relevant information concerning the patient). Hence the condition is either assignedEntity is present or relatedEntity is present. 
   
       
ContextSibling nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.4.6
LabelPaLM Suppl. APSR 2.0‑3: 6.3.6.5 Informant
ClassificationTemplate type not specified
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 32 templates, Uses 2 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.3.10.4.2ContainmentKyellow.png TNM Stage Observation (2.0)2014‑05‑13 15:45:13
1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.3.10.4.3ContainmentKyellow.png ICD-O-3 Typing and Grading Observation (2.0)2015‑11‑29 17:03:18
1.3.6.1.4.1.19376.1.3.10.4.4ContainmentKyellow.png Assessment Scales Observation for Scoring Systems APSR2 (2.0)2016‑10‑06 13:12:00
1.3.6.1.4.1.19376.1.3.10.9.22ContainmentKyellow.png CDA Supply Container APSR2 (2.0)2016‑07‑29 12:09:33
1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.8.1.2.6Link.pngKyellow.png Procedure Steps Section (2.0)2014‑05‑13 19:33:12
1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.3.10.9.25ContainmentKyellow.png TNM T-Observation (2.0)2014‑12‑02 15:54:17
1.3.6.1.4.1.19376.1.3.10.9.26ContainmentKyellow.png TNM N-Observation (2.0)2014‑12‑02 16:34:50
1.3.6.1.4.1.19376.1.3.10.9.27ContainmentKyellow.png TNM M-Observation (2.0)2014‑12‑02 16:32:30
1.3.6.1.4.1.19376.1.3.10.9.28ContainmentKyellow.png TNM Grading (2.0)2015‑11‑15 13:01:18
1.3.6.1.4.1.19376.1.3.10.9.29ContainmentKyellow.png TNM R-status (2.0)2015‑06‑30 13:38:30
1.3.6.1.4.1.19376.1.3.10.9.30ContainmentKyellow.png TNM a (2.0)2015‑06‑22 15:13:46
1.3.6.1.4.1.19376.1.3.10.9.31ContainmentKyellow.png TNM r (2.0)2015‑06‑22 17:38:42
1.3.6.1.4.1.19376.1.3.10.9.32ContainmentKyellow.png TNM y (2.0)2015‑06‑22 17:28:17
1.3.6.1.4.1.19376.1.3.10.9.33ContainmentKyellow.png TNM Serum tumor markers (2.0)2015‑11‑06 14:28:44
1.3.6.1.4.1.19376.1.3.10.9.34ContainmentKyellow.png TNM Lymphatic Invasion (2.0)2015‑11‑16 14:01:58
1.3.6.1.4.1.19376.1.3.10.9.35ContainmentKyellow.png TNM Venous Invasion (2.0)2015‑11‑16 13:40:28
1.3.6.1.4.1.19376.1.3.10.9.36ContainmentKyellow.png TNM Perineural Invasion (2.0)2015‑11‑11 16:13:40
1.3.6.1.4.1.19376.1.3.10.9.37ContainmentKyellow.png TNM Number of nodes (2.0)2014‑12‑02 16:48:36
1.3.6.1.4.1.19376.1.3.10.9.43ContainmentKyellow.png Assessment Scoring Item APSR 2.0 (2.0)2016‑10‑11 10:26:17
1.3.6.1.4.1.19376.1.3.10.9.42Link.pngKyellow.png Assessment Scoring System APSR 2.0 (2.0)2016‑10‑10 11:33:36
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.3.10.3.1Link.pngKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.2.1Link.pngKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2Link.pngKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3Link.pngKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4Link.pngKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5Link.pngKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.4.10ContainmentKyellow.png Embedded Image IHE2016‑06‑22 16:08:01
1.3.6.1.4.1.19376.1.8.1.4.9Link.pngKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
Uses as NameVersion
2.16.840.1.113883.10.12.153ContainmentKgreen.png CDA AssignedEntity2005‑09‑07
2.16.840.1.113883.10.12.316ContainmentKgreen.png CDA RelatedEntity2005‑09‑07
RelationshipAdaptation: template 2.16.840.1.113883.10.12.319 (2005‑09‑07)
Example
Example
<!-- choice: 1..1
element hl7:assignedEntity containing template 2.16.840.1.113883.10.12.153 (dynamic)
element hl7:relatedEntity containing template 2.16.840.1.113883.10.12.316 (dynamic)
-->
ItemDTCardConfDescriptionLabel
@typeCode
cs0 … 1FINF
@context​Control​Code
cs0 … 1FOP
hl7:templateId
II1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.5 Informant
Treetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.6
Choice0 … 1
The 

informant  is either an  assignedEntity  (i.e. a person playing an identified role in the process of care) or a  relatedEntity

 (a person related to the patient)
Elements to choose from:
  • hl7:assignedEntity containing template 2.16.840.1.113883.10.12.153 CDA AssignedEntity (2005‑09‑07)
  • hl7:relatedEntity containing template 2.16.840.1.113883.10.12.316 CDA RelatedEntity (2005‑09‑07)
Treetree.pnghl7:assignedEntity
0 … 1CContains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (2005‑09‑07)PaLM Suppl. APSR 2.0‑3: 6.3.6.5 Informant
Treetree.pnghl7:relatedEntity
0 … 1CContains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (2005‑09‑07)PaLM Suppl. APSR 2.0‑3: 6.3.6.5 Informant

6.3.6.6 Additional participant in an entry - 1.3.6.1.4.1.19376.1.8.1.4.7

6.3.6.6.1 Definition and purpose

This Content Module is usable only within an <entry> element.

Additional participants MAY take part in any organizer as well as in any observation of an APSR. These participants MAY be any of these 4:

  • Validator: This is the same participation as Content Validator in the header of the report: a pathologist having verified the content (of this particular subset of results).
  • Device: A device used to produce this particular subset of results.
  • Responsible: The director of a laboratory (described in a performer element at the same level) who produced this particular subset of results.
  • Transcriptionist: This is the same participation as dataEnterer in the header of the report: a staff who entered, possibly from dictation, this particular subset of results.
6.3.6.6.2 Specification and Example
Id1.3.6.1.4.1.19376.1.8.1.4.7Effective Date valid from 2016‑07‑12 18:44:06
StatusKyellow.png DraftVersion Label
NameAdditionalParticipantAPSRDisplay NameAdditional participant in an entry APSR (Body)
DescriptionTemplate CDA Participant (Body) (prototype, directly derived from POCD_RM000040 MIF)
LabelPaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 18 templates, Uses 2 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.3.10.4.2ContainmentKyellow.png TNM Stage Observation (2.0)2014‑05‑13 15:45:13
1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
1.3.6.1.4.1.19376.1.3.10.4.3ContainmentKyellow.png ICD-O-3 Typing and Grading Observation (2.0)2015‑11‑29 17:03:18
1.3.6.1.4.1.19376.1.3.10.4.4ContainmentKyellow.png Assessment Scales Observation for Scoring Systems APSR2 (2.0)2016‑10‑06 13:12:00
1.3.6.1.4.1.19376.1.3.10.9.26ContainmentKyellow.png TNM N-Observation (2.0)2014‑12‑02 16:34:50
1.3.6.1.4.1.19376.1.3.10.9.27ContainmentKyellow.png TNM M-Observation (2.0)2014‑12‑02 16:32:30
1.3.6.1.4.1.19376.1.3.10.9.37ContainmentKyellow.png TNM Number of nodes (2.0)2014‑12‑02 16:48:36
1.3.6.1.4.1.19376.1.3.10.9.43ContainmentKyellow.png Assessment Scoring Item APSR 2.0 (2.0)2016‑10‑11 10:26:17
1.3.6.1.4.1.19376.1.3.10.9.42Link.pngKyellow.png Assessment Scoring System APSR 2.0 (2.0)2016‑10‑10 11:33:36
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.3.10.3.1Link.pngKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.1Link.pngKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2Link.pngKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3Link.pngKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4Link.pngKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5Link.pngKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
Uses as NameVersion
2.16.840.1.113883.10.12.315ContainmentKgreen.png CDA Device2005‑09‑07
2.16.840.1.113883.10.12.313ContainmentKgreen.png CDA PlayingEntity2005‑09‑07
RelationshipAdaptation: template 2.16.840.1.113883.10.12.321 (2005‑09‑07)
Example
generated example
<templateId root="1.3.6.1.4.1.19376.1.8.1.4.7"/><time/><participantRole classCode="ROL">
  <id root="1.2.3.999" extension="--example only--"/>  <addr>addr</addr>  <telecom value="tel:+1-12345678"/>  <!-- choice: 0..1
element hl7:playingDevice containing template 2.16.840.1.113883.10.12.315 (dynamic)
element hl7:playingEntity containing template 2.16.840.1.113883.10.12.313 (dynamic)
-->
</participantRole>
ItemDTCardConfDescriptionLabel
@typeCode
cs1 … 1R

participant[@participationType="AUTHEN" 
or @participationType="DEV" 
or @participationType="RESP" 
or @participationType="ENT"]

   
       
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.10901 ParticipationType (2014‑03‑26)
@context​Control​Code
cs0 … 1FOP
hl7:templateId
II1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
Treetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.7
hl7:time
TS0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
hl7:participantRole
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
Treetree.png@classCode
cs0 … 1FROL
Treetree.pnghl7:id
II0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
Treetree.pnghl7:addr
AD0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
Treetree.pnghl7:telecom
TEL0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
Choice0 … 1Elements to choose from:
  • hl7:playingDevice containing template 2.16.840.1.113883.10.12.315 CDA Device (2005‑09‑07)
  • hl7:playingEntity containing template 2.16.840.1.113883.10.12.313 CDA PlayingEntity (2005‑09‑07)
 ConstraintIf the participationType is DEV, then the playingDevice sub-element SHALL be present and the playingEntity sub-element SHALL NOT be present.  

In all other cases the playingDevice sub-element SHALL NOT be present and the playingEntity sub-element SHALL be present.
Treeblank.pngTreetree.pnghl7:playingDevice
0 … 1CContains 2.16.840.1.113883.10.12.315 CDA Device (2005‑09‑07)PaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
 ConstraintWhen the participant is a device at least one of the sub-elements code

softwareName  and

manufacturerModelName SHALL be present.
Treeblank.pngTreetree.pnghl7:playingEntity
0 … 1CContains 2.16.840.1.113883.10.12.313 CDA PlayingEntity (2005‑09‑07)PaLM Suppl. APSR 2.0‑3: 6.3.6.6 Additional participant
 Constraintonly name(s) SHALL be given

6.3.6.7 Anatomic Pathology Observation template – 1.3.6.1.4.1.19376.1.8.1.4.9

6.3.6.7.1 Definition and purpose

This Content Module is usable within a Problem Organizer.

The “AP Observation” generic template is usable for all AP observations, including those on findings from ancillary techniques.

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. For measurement results the UCUM system should be used.

6.3.6.7.2 Specification and Example
Id1.3.6.1.4.1.19376.1.8.1.4.9Effective Date valid from 2014‑05‑14 17:09:54
StatusKyellow.png DraftVersion Label2.0
NameAPObservationEntryDisplay NameAP Observation Entry
Description
This content module is usable within a Problem organizer.
   
The “AP Observation” generic template is usable for all AP observations, including ancillary techniques. 

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.

ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.4.9
LabelPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 9 templates, Uses 10 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.3.10.3.1Link.pngKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.1Link.pngKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2Link.pngKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3Link.pngKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4Link.pngKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5Link.pngKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)2016‑07‑08 11:22:58
1.3.6.1.4.1.19376.1.8.1.4.7ContainmentKyellow.png Additional participant in an entry APSR (Body)2016‑07‑12 18:44:06
1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
1.3.6.1.4.1.19376.1.8.1.4.10ContainmentKyellow.png Embedded Image IHE2016‑06‑22 16:08:01
2.16.840.1.113883.10.12.307ContainmentKgreen.png CDA RegionOfInterest2005‑09‑07
1.3.6.1.4.1.19376.1.5.3.1.4.2ContainmentKgreen.png IHE Comment Entry (2014)2013‑12‑20
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA Reference2005‑09‑07
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Example
Observation example for use case #1, estrogen receptor
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.4.9"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="16112-5" codeSystem="2.16.840.1.113883.6.1" displayName="Estrogen receptor [Interpretation] in Tissue"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20161129162112"/>  </effectiveTime>
  <value xsi:type="CD" code="416053008" displayName="Estrogen receptor positive tumor (disorder)" codeSystem="2.16.840.1.113883.6.96"/>  <methodCode code="0107" displayName="Microscopy" codeSystem="2.16.840.1.113883.5.84"/>  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'CDA Performer IHE (Body)' (dynamic) -->
  </performer>
  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) -->
  </author>
  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Body) APSR2' (dynamic) -->
  </informant>
  <participant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (dynamic) -->
  </participant>
  <entryRelationship xsi:type="" typeCode="COMP">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (dynamic) -->
  </entryRelationship>
  <entryRelationship xsi:type="" typeCode="COMP">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (dynamic) -->
  </entryRelationship>
  <entryRelationship xsi:type="" typeCode="COMP">
    <!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' (dynamic) -->
  </entryRelationship>
  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (dynamic) 0..* O -->
  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (dynamic) -->
  </reference>
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … *RPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1MPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.9
Treetree.pnghl7:id
II0 … *RPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treetree.pnghl7:code
CE (extensible)1 … 1MThe Anatomic pathology observation code should be taken from a reference terminology, preferably the LOINC terminology. National terminologies may be used.PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.pngTreetree.png@code
CONF1 … 1Feach_code_for_observable_entities_or_a_specific_procedure
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1Fsee_above
 Example<code code="59847-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Histology and Behavior ICD-O-3"/>
Treetree.pnghl7:text
ED0 … 1RNarrative text about the observationPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treetree.pnghl7:statusCode
CS (required)1 … 1MThe observation statusCode is “completed” if the observation was actually performed and has produced a result in the 

value  

element. In other cases the status of the intended observation is “aborted” and the result will never come.
PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 (DYNAMIC)
Alert.pngError: Cannot find value set "1.3.6.1.4.1.19376.1.3.11.2"
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1MDate and time the observation has been made
PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treetree.pnghl7:value
ANY0 … *RObservation values using the appropriate data type.


Numeric results use data type PQ, which includes the unit. The result is absent in case of ‘aborted’ observation.


PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
 ConstraintThe default data type, cardinalities and value set for the <value> element are dependant on the type of observation.
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.11 AP Observation (2015‑11‑22 12:20:34)
 Example
for observation on tumor type
<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"/>
Treetree.pnghl7:interpretationCode
CE (extensible)0 … 1R

One or more codes interpreting the result, expressed with ObservationInterpretation vocabulary (e.g., H = high, L = low). 

    This element may be coded with other values than those of the ObservationInterpretation vocabulary, given that the coding strength is CWE (coded with exceptions).

PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)
Treetree.pnghl7:methodCode
CE (extensible)0 … 1RPaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (2014‑03‑26)
Treetree.pnghl7:performer
II0 … 1CPerforming lab


Source: PaLM TF-3: 6.3.2.20



Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)
PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
 ConstraintThe performing laboratory is present at this level only if this particular observation was performed by a (subcontractor) laboratory distinct from the one issuing the rest of the observations in this organizer.
Treetree.pnghl7:author
II0 … *CAuthor


   Source: PaLM TF Suppl. APSR 2.0-3:
    6.3.6.2

Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.png where [hl7:author [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.2']]]
Treetree.pnghl7:informant
II0 … *RInformant


Source: PaLM TF Suppl. APSR 2.0-3 : 6.3.6.5



Contains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (2016‑07‑08 11:22:58)
PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.6']]
Treetree.pnghl7:participant
II0 … *RAdditional participants


Source: PaLM TF Suppl. APSR 2.0-3 : 6.3.6.6



Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry APSR (Body) (2016‑07‑12 18:44:06)
PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.7']]
Treetree.pnghl7:entryRelationship
0 … *RSub-Observation


The result obtained for an observation may lead to an additional AP observation to refine this result. This sub-observation is again an Anatomic Pathology Observation.

   
       
Source: 
Source: PaLM TF Suppl. APSR 2.0-3 : 6.3.6.7

Contains 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54)
PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.png where [@typeCode='COMP'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.9']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7:entryRelationship
0 … *REmbedded image. 


This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest. 

Source: PaLM TF Suppl. APSR 2.0-3 : 6.3.6.8

   
       

Contains 1.3.6.1.4.1.19376.1.8.1.4.10 Embedded Image IHE (2016‑06‑22 16:08:01)
PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.png where [@typeCode='COMP'] [hl7:observationMedia [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.10']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7:entryRelationship
0 … *RRegion of Interest






   
       

Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (2005‑09‑07)
PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.png where [@typeCode='COMP'] [hl7:regionOfInterest [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.12.307']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
 ConstraintThis observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest.
In the latter case by an entryRelationship @typeCode="SUBJ"
Treetree.pnghl7:entryRelationship
0 … *RAnnotation comment






   
       

Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20)
PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation
Treeblank.png where [hl7:act [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.20.1.40'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.2']]]
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCOMP
Included1 … *M from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Specimen identification
 Example
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>
Treetree.pnghl7:specimen
1 … *MRequired in XD-LAB when more than one specimen is documented at this level. Always required in APSR.
PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreetree.png@typeCode
cs0 … 1FSPC
Treeblank.pngTreetree.pnghl7:specimenRole
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FSPEC
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treetree.pnghl7:reference
0 … *RReference to an external document, or to external observations, e.g. concerning molecular pathology or  genetic testing report
Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)
PaLM TF Suppl. APSR 2.0‑3: 6.3.6.7 AP observation

6.3.6.8 Embedded Image – 1.3.6.1.4.1.19376.1.8.1.4.10

6.3.6.8.1 Definition and purpose

This Content Module is usable within an <entry> element, in relationship with a display anchor carried in the referencedObject attribute of a <renderMultimedia> element in the <text> element of the <section> holding this <entry>.


The <observationMedia> element carries an image, embedded in B64. This element may be standalone, or encapsulated within a <regionOfInterest> element which defines an overlay shape to focus on a part of the image.

This <observationMedia> element embeds the image binary data, encoded in B64.

6.3.6.8.2 Specification and Example
Id1.3.6.1.4.1.19376.1.8.1.4.10Effective Date valid from 2016‑06‑22 16:08:01
StatusKyellow.png DraftVersion Label
NameEmbeddedImageIHEDisplay NameEmbedded Image IHE
Description
Template CDA ObservationMedia (prototype, directly derived from POCD_RM000040 MIF)


This Content Module is usable within an <entry> element, in relationship with a display anchor carried in the referencedObject attribute of a <renderMultimedia> element in the <text> element of the <section> holding this <entry>.

The <observationMedia> element carries an image, embedded in B64. This element may be standalone, or encapsulated within a <regionOfInterest> element which defines an overlay shape to focus on a part of the image.

This <observationMedia> element embeds the image binary data, encoded in B64. 

ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.4.10
LabelPaLM TF‑3: 6.3.4.14 Embedded image
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 9 templates, Uses 5 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.3.10.3.1Link.pngKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.1Link.pngKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2Link.pngKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3Link.pngKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4Link.pngKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5Link.pngKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)2016‑07‑08 11:22:58
1.3.6.1.4.1.19376.1.5.3.1.4.2ContainmentKgreen.png IHE Comment Entry (2014)2013‑12‑20
RelationshipSpecialization: template 2.16.840.1.113883.10.12.304 (2005‑09‑07)
Example
generated example
<observationMedia classCode="OBS" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.4.10"/>  <id root="1.2.3.999" extension="--example only--"/>  <languageCode code="en"/>  <value mediaType="application" representation="B64"/>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 1..1 M -->
  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->
  </performer>
  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->
  </author>
  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->
  </informant>
  <entryRelationship negationInd="false" typeCode="SUBJ" inversionInd="true" contextConductionInd="true">
    <sequenceNumber value="1"/>    <seperatableInd value="false"/>    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.4.2 'IHE Comment Entry' (2013-12-20T00:00:00) -->
  </entryRelationship>
</observationMedia>
ItemDTCardConfDescriptionLabel
hl7:observationMedia
0 … *REmbedded ImagePaLM TF‑3: 6.3.4.14 Embedded image
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1MPaLM TF‑3: 6.3.4.14 Embedded image
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.10
Treetree.pnghl7:id
II0 … *R

   The ID attribute is pointed to by the anchor in the referencedObject attribute of a <renderMultimedia> element in the <text> element of the <section> holding this <entry>.

PaLM TF‑3: 6.3.4.14 Embedded image
Treetree.pnghl7:value
1 … 1RPaLM TF‑3: 6.3.4.14 Embedded image
Treeblank.pngTreetree.png@representation
cs1 … 1FB64
Treeblank.pngTreetree.png@mediaType
cs1 … 1RThe mediaType attribute specifies the type of media/application to be used to display the image. For instance ‘image/gif’ or ‘image/jpeg’.

 


 CONF
The value of @mediaType shall be drawn from value set 2.16.840.1.113883.1.11.14824 MediaType (DYNAMIC)
 ConstraintThe <value> element contains the image encoded in Base 64. This is indicated by the value “B64”of attribute representation
Included1 … 1M from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Treetree.pnghl7:specimen
1 … 1MRequired in XD-LAB when more than one specimen is documented at this level. Always required in APSR.
PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreetree.png@typeCode
cs0 … 1FSPC
Treeblank.pngTreetree.pnghl7:specimenRole
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FSPEC
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treetree.pnghl7:performer
0 … *CContains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)PaLM TF‑3: 6.3.4.14 Embedded image
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
Treetree.pnghl7:author
0 … *CContains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)PaLM TF‑3: 6.3.4.14 Embedded image
Treeblank.png where [hl7:author [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.2']]]
Treetree.pnghl7:informant
0 … *RContains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (2016‑07‑08 11:22:58)PaLM TF‑3: 6.3.4.14 Embedded image
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.6']]
Treetree.pnghl7:entryRelationship
0 … *RComment on this image.

Source: PCC TF-2: 6.3.4.6
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20)
PaLM TF‑3: 6.3.4.14 Embedded image
Treeblank.png where [@typeCode='SUBJ'] [hl7:act [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.20.1.40'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.2']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSUBJ
Treeblank.pngTreetree.png@inversionInd
bl0 … 1Ftrue

6.3.6.9 X Specimen Identified - 1.3.6.1.4.1.19376.1.3.10.9.1

6.3.6.9.1 Definition and purpose

This Specimen Identification <entry> provides the machine-readable links between any type of procedure or observation or embedded image or containers to the specimen, on that this procedure is performed (parent specimen), or from which this observation or image is obtained. It is required when more than one specimen is documented at this level. It is only used in PaLM templates for Problem Organizer, Specimen Procedure Steps, Observations, Embedded images, and Containers in Specimen Procedure Steps.

6.3.6.9.2 Specification and Example
Id1.3.6.1.4.1.19376.1.3.10.9.1Effective Date valid from 2014‑12‑22 15:54:30
StatusKyellow.png DraftVersion Label
NameSpecimenIdentifiedDisplay NameX Specimen Identified
Description
Template CDA Specimen (prototype, directly derived from POCD_RM000040 MIF)

Entry template for linking specimen ID to observation or to procedure.
Required in XD-LAB when more than one specimen is documented at this level. 
LabelPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 32 templates, Uses 0 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.3.10.4.1IncludeKyellow.png Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.3.10.4.1Link.pngKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.3.10.4.1, please check
1.3.6.1.4.1.19376.1.8.1.2.6Link.pngKyellow.png Procedure Steps Section (2.0)2014‑05‑13 19:33:12
1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.3.10.4.2IncludeKyellow.png TNM Stage Observation (2.0)2014‑05‑13 15:45:13
1.3.6.1.4.1.19376.1.3.10.4.3IncludeKyellow.png ICD-O-3 Typing and Grading Observation (2.0)2015‑11‑29 17:03:18
1.3.6.1.4.1.19376.1.3.10.4.4IncludeKyellow.png Assessment Scales Observation for Scoring Systems APSR2 (2.0)2016‑10‑06 13:12:00
1.3.6.1.4.1.19376.1.3.10.9.22IncludeKyellow.png CDA Supply Container APSR2 (2.0)2016‑07‑29 12:09:33
1.3.6.1.4.1.19376.1.3.10.9.25IncludeKyellow.png TNM T-Observation (2.0)2014‑12‑02 15:54:17
1.3.6.1.4.1.19376.1.3.10.9.26IncludeKyellow.png TNM N-Observation (2.0)2014‑12‑02 16:34:50
1.3.6.1.4.1.19376.1.3.10.9.27IncludeKyellow.png TNM M-Observation (2.0)2014‑12‑02 16:32:30
1.3.6.1.4.1.19376.1.3.10.9.28IncludeKyellow.png TNM Grading (2.0)2015‑11‑15 13:01:18
1.3.6.1.4.1.19376.1.3.10.9.29IncludeKyellow.png TNM R-status (2.0)2015‑06‑30 13:38:30
1.3.6.1.4.1.19376.1.3.10.9.34IncludeKyellow.png TNM Lymphatic Invasion (2.0)2015‑11‑16 14:01:58
1.3.6.1.4.1.19376.1.3.10.9.35IncludeKyellow.png TNM Venous Invasion (2.0)2015‑11‑16 13:40:28
1.3.6.1.4.1.19376.1.3.10.9.36IncludeKyellow.png TNM Perineural Invasion (2.0)2015‑11‑11 16:13:40
1.3.6.1.4.1.19376.1.3.10.9.37IncludeKyellow.png TNM Number of nodes (2.0)2014‑12‑02 16:48:36
1.3.6.1.4.1.19376.1.3.10.9.38IncludeKyellow.png ICD-O-3 Behavior (2.0)2015‑12‑03 09:11:54
1.3.6.1.4.1.19376.1.3.10.9.39IncludeKyellow.png ICD-O-3 Differentiation (2.0)2015‑12‑09 17:12:30
1.3.6.1.4.1.19376.1.3.10.9.40IncludeKyellow.png ICD-O-3 Morphology (1.0)2015‑11‑29 15:45:48
1.3.6.1.4.1.19376.1.3.10.9.41IncludeKyellow.png ICD-O-3 Topography (2.0)2015‑11‑16 18:38:07
1.3.6.1.4.1.19376.1.3.10.9.42IncludeKyellow.png Assessment Scoring System APSR 2.0 (2.0)2016‑10‑10 11:33:36
1.3.6.1.4.1.19376.1.3.10.9.43IncludeKyellow.png Assessment Scoring Item APSR 2.0 (2.0)2016‑10‑11 10:26:17
1.3.6.1.4.1.19376.1.8.1.3.6IncludeKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.3.10.3.1Link.pngKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.2.1Link.pngKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2Link.pngKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3Link.pngKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4Link.pngKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5Link.pngKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.4.10IncludeKyellow.png Embedded Image IHE2016‑06‑22 16:08:01
1.3.6.1.4.1.19376.1.8.1.4.9Link.pngKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
Notice.png Circular reference found with 1.3.6.1.4.1.19376.1.8.1.4.9, please check
RelationshipSpecialization: template 2.16.840.1.113883.10.12.322 (2005‑09‑07)
Example
Example
<specimen typeCode="SPC">
  <specimenRole classCode="SPEC">
    <id root="1.2.3.999" extension="--example only, coming from the LIS--"/>  </specimenRole>
</specimen>
ItemDTCardConfDescriptionLabel
hl7:specimen
0 … 1RRequired in XD-LAB when more than one specimen is documented at this level. Always required in APSR.
PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treetree.png@typeCode
cs0 … 1FSPC
Treetree.pnghl7:specimenRole
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreetree.png@classCode
cs0 … 1FSPEC
Treeblank.pngTreetree.pnghl7:id
II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified

6.3.6.10 UICC/AJCC TNM Staging and Grading - 1.3.6.1.4.1.19376.1.3.10.4.2

6.3.6.10.1 Definition and purpose

The UICC/AJCC TNM <entry> Content Modul contains in machine-readable form all the information concerning a TNM formula for a problem investigated. It is a constraint version of an AP Generic observation <entry> Content Module. It is usable within a Problem Organizer <entry> Content Module only.

This Content Module structures the machine-readable data, which characterize the staging and grading of a malignant Tumor according the UICC/AJCC regulations for the TNM system. A series of supporting templates is used for all the detailed descriptions of the elements of the TNM system.

6.2.6.12.1-1 1.jpeg

Figure 6.3.6.10.1-1 CDA-RMIM of the UICC/AJCC TNM <entry>

6.3.6.10.2 Specification and Example
Id1.3.6.1.4.1.19376.1.3.10.4.2Effective Date valid from 2014‑05‑13 15:45:13
StatusKyellow.png DraftVersion Label2.0
NameTNMStageObservationDisplay NameTNM Stage Observation
DescriptionTemplate CDA Observation (prototype, directly derived from POCD_RM000040 MIF)

TNM stage with supporting categories
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.2
LabelPaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 17 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKcancelledblue.png Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)2016‑07‑08 11:22:58
1.3.6.1.4.1.19376.1.8.1.4.7ContainmentKyellow.png Additional participant in an entry APSR (Body)2016‑07‑12 18:44:06
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.3.10.9.32ContainmentKyellow.png TNM y (2.0)2015‑06‑22 17:28:17
1.3.6.1.4.1.19376.1.3.10.9.30ContainmentKyellow.png TNM a (2.0)2015‑06‑22 15:13:46
1.3.6.1.4.1.19376.1.3.10.9.31ContainmentKyellow.png TNM r (2.0)2015‑06‑22 17:38:42
1.3.6.1.4.1.19376.1.3.10.9.25ContainmentKyellow.png TNM T-Observation (2.0)2014‑12‑02 15:54:17
1.3.6.1.4.1.19376.1.3.10.9.26ContainmentKyellow.png TNM N-Observation (2.0)2014‑12‑02 16:34:50
1.3.6.1.4.1.19376.1.3.10.9.27ContainmentKyellow.png TNM M-Observation (2.0)2014‑12‑02 16:32:30
1.3.6.1.4.1.19376.1.3.10.9.33ContainmentKyellow.png TNM Serum tumor markers (2.0)2015‑11‑06 14:28:44
1.3.6.1.4.1.19376.1.3.10.9.34ContainmentKyellow.png TNM Lymphatic Invasion (2.0)2015‑11‑16 14:01:58
1.3.6.1.4.1.19376.1.3.10.9.35ContainmentKyellow.png TNM Venous Invasion (2.0)2015‑11‑16 13:40:28
1.3.6.1.4.1.19376.1.3.10.9.36ContainmentKyellow.png TNM Perineural Invasion (2.0)2015‑11‑11 16:13:40
1.3.6.1.4.1.19376.1.3.10.9.28ContainmentKyellow.png TNM Grading (2.0)2015‑11‑15 13:01:18
1.3.6.1.4.1.19376.1.3.10.9.29ContainmentKyellow.png TNM R-status (2.0)2015‑06‑30 13:38:30
RelationshipSpecialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 (2014‑05‑14 17:09:54)
Example
Generated example
<observation classCode="OBS" moodCode="ENV" negationInd="false">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.4.2"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="21902-2" codeSystem="2.16.840.1.113883.6.1"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20170712152253"/>  </effectiveTime>
  <value xsi:type="CD" code="IIA" displayName="stage IIA" codeSystem="2.16.840.1.113883.15.6"/>  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->
  </performer>
  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->
  </author>
  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->
  </informant>
  <participant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (2016-07-12T18:44:06) -->
  </participant>
  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 1..* M -->
  <entryRelationship>
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.32 'TNM y' (2015-06-22T17:28:17) -->
  </entryRelationship>
  <entryRelationship>
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.30 'TNM a ' (2015-06-22T15:13:46) -->
  </entryRelationship>
  <entryRelationship>
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.31 'TNM r' (2015-06-22T17:38:42) -->
  </entryRelationship>
  <entryRelationship>
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.25 'TNM T-Observation' (2014-12-02T15:54:17) -->
  </entryRelationship>
  <entryRelationship>
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.26 'TNM N-Observation' (2014-12-02T16:34:50) -->
  </entryRelationship>
  <entryRelationship>
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.27 'TNM M-Observation' (2014-12-02T16:32:30) -->
  </entryRelationship>
  <entryRelationship>
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.33 'TNM Serum tumor markers' (2015-11-06T14:28:44) -->
  </entryRelationship>
  <entryRelationship>
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.34 'TNM Lymphatic Invasion' (2015-11-16T14:01:58) -->
  </entryRelationship>
  <entryRelationship>
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.35 'TNM Venous Invasion' (2015-11-16T13:40:28) -->
  </entryRelationship>
  <entryRelationship>
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.36 'TNM Perineural Invasion' (2015-11-11T16:13:40) -->
  </entryRelationship>
  <entryRelationship>
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.28 'TNM Grading' (2015-11-15T13:01:18) -->
  </entryRelationship>
  <entryRelationship>
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.29 'TNM R-status' (2015-06-30T13:38:30) -->
  </entryRelationship>
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FENV
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.4.2
Treetree.pnghl7:id
II0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treetree.pnghl7:code
CE (extensible)1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
 CONF
@code shall be "21902-2"
@codeSystem shall be "2.16.840.1.113883.6.1"
@codeSystemName shall be "LOINC"
or
@code shall be "tnmStage"
@codeSystem shall be "1.2.276.0.76.3.1.131.1.5.1"
@codeSystemName shall be "DKG Coding Scheme"
@displayName shall be "tumor stage"
Treetree.pnghl7:text
ED0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
 Example<text> PATHOLOGIC STAGE (AJCC 7th Edition): IIA </text>
Treetree.pnghl7:statusCode
CS (required)1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
 ConstraintThe observation statusCode is “

completed ” if the observation was actually performed and has produced a result in the  value  element. In other cases the status of the intended observation is “ aborted ” and the result will never come.


 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 (DYNAMIC)
Alert.pngError: Cannot find value set "1.3.6.1.4.1.19376.1.3.11.2"
or
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (2014‑03‑26)
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treetree.pnghl7:value
CD (extensible)0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
 CONF
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.46 UICC Stage (2017‑07‑21 10:43:31)
Treetree.pnghl7:performer
II0 … 1CPerforming lab


Source: PaLM TF-3: 6.3.2.20



Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)
PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
 ConstraintThe performing laboratory is present at this level only if this particular observation was performed by a (subcontractor) laboratory distinct from the one issuing the rest of the observations in this organizer.
Treetree.pnghl7:author
II0 … *CAuthor


   Source: PaLM TF Suppl. APSR 2.0-3:
    6.3.6.2

Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treeblank.png where [hl7:author [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.2']]]
Treetree.pnghl7:informant
II0 … *RInformant


Source: PaLM TF Suppl. APSR 2.0-3 : 6.3.6.5



Contains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (2016‑07‑08 11:22:58)
PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.6']]
Treetree.pnghl7:participant
II0 … *RAdditional participants


Source: PaLM TF Suppl. APSR 2.0-3 : 6.3.6.6



Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry APSR (Body) (2016‑07‑12 18:44:06)
PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.7']]
Included1 … *M from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Treetree.pnghl7:specimen
1 … *MRequired in XD-LAB when more than one specimen is documented at this level. Always required in APSR.
PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreetree.png@typeCode
cs0 … 1FSPC
Treeblank.pngTreetree.pnghl7:specimenRole
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FSPEC
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treetree.pnghl7:entryRelationship
0 … 1Rstaged after multimodal (neoadjuvant) therapy

Contains 1.3.6.1.4.1.19376.1.3.10.9.32 TNM y (2015‑06‑22 17:28:17)
PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.32']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treetree.pnghl7:entryRelationship
0 … 1Rfirst staged at autopsy
Contains 1.3.6.1.4.1.19376.1.3.10.9.30 TNM a (2015‑06‑22 15:13:46)
PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.30']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treetree.pnghl7:entryRelationship
0 … 1Rstaged after relapse
Contains 1.3.6.1.4.1.19376.1.3.10.9.31 TNM r (2015‑06‑22 17:38:42)
PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.31']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treetree.pnghl7:entryRelationship
1 … 1RT: T category of TNM

Contains 1.3.6.1.4.1.19376.1.3.10.9.25 TNM T-Observation (2014‑12‑02 15:54:17)
PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.25']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treetree.pnghl7:entryRelationship
1 … 1RN: N category of TNM

Contains 1.3.6.1.4.1.19376.1.3.10.9.26 TNM N-Observation (2014‑12‑02 16:34:50)
PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.26']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treetree.pnghl7:entryRelationship
0 … 1RM: M category of TNM

Contains 1.3.6.1.4.1.19376.1.3.10.9.27 TNM M-Observation (2014‑12‑02 16:32:30)
PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.27']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treetree.pnghl7:entryRelationship
0 … 1RSerum tumor markers stage descriptor
Contains 1.3.6.1.4.1.19376.1.3.10.9.33 TNM Serum tumor markers (2015‑11‑06 14:28:44)
PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.33']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treetree.pnghl7:entryRelationship
0 … 1RDescriptor for lymphatic invasion
Contains 1.3.6.1.4.1.19376.1.3.10.9.34 TNM Lymphatic Invasion (2015‑11‑16 14:01:58)
PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.34']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treetree.pnghl7:entryRelationship
0 … 1RDescriptor for venous invasion

Contains 1.3.6.1.4.1.19376.1.3.10.9.35 TNM Venous Invasion (2015‑11‑16 13:40:28)
PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.35']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treetree.pnghl7:entryRelationship
0 … 1RDescriptor for perineurial invasion

Contains 1.3.6.1.4.1.19376.1.3.10.9.36 TNM Perineural Invasion (2015‑11‑11 16:13:40)
PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.36']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treetree.pnghl7:entryRelationship
1 … 1RTNM-Grading
Contains 1.3.6.1.4.1.19376.1.3.10.9.28 TNM Grading (2015‑11‑15 13:01:18)
PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.28']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treetree.pnghl7:entryRelationship
0 … 1RStatus of residual tumor
Contains 1.3.6.1.4.1.19376.1.3.10.9.29 TNM R-status (2015‑06‑30 13:38:30)
PaLM Suppl. APSR 2.0‑3: 6.3.6.10 TNM
Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.29']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT

6.3.6.11 ICD-O-3 Typing and Grading - 1.3.6.1.4.1.19376.1.3.10.4.3

6.3.6.11.1 Definition and purpose

The ICD-O-3 Typing and Grading<entry> Content Modul contains in machine-readable form all the information concerning ICD-O-3 Typing and Grading for a problem investigated. It is a constraint version of an AP Generic observation <entry> Content Module. It is usable within a Problem Organizer <entry> Content Module only.

This Content Module structures the machine-readable data, which characterize the typing and grading of a tumor or a systemic malignancy according the WHO regulations for the ICD-O-3 system. A series of supporting templates is used for all the detailed descriptions of the elements of the ICD-O-3 system.

6.2.6.13.1-1 1.jpeg

Figure 6.3.6.11.1-1 CDA-RMIM of the ICD-O-3 <entry>

6.3.6.11.2 Specification and Example
Id1.3.6.1.4.1.19376.1.3.10.4.3Effective Date valid from 2015‑11‑29 17:03:18
StatusKyellow.png DraftVersion Label2.0
NameICD-O-3TypingGradingDisplay NameICD-O-3 Typing and Grading Observation
DescriptionTemplate CDA Observation (prototype, directly derived from POCD_RM000040 MIF)

Entry template for observation on ICD-O-3 Typing and Grading
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.3
LabelPaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 9 templates
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)2016‑07‑08 11:22:58
1.3.6.1.4.1.19376.1.8.1.4.7ContainmentKyellow.png Additional participant in an entry APSR (Body)2016‑07‑12 18:44:06
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.3.10.9.38ContainmentKyellow.png ICD-O-3 Behavior (2.0)2015‑12‑03 09:11:54
1.3.6.1.4.1.19376.1.3.10.9.39ContainmentKyellow.png ICD-O-3 Differentiation (2.0)2015‑12‑09 17:12:30
1.3.6.1.4.1.19376.1.3.10.4.4ContainmentKyellow.png Assessment Scales Observation for Scoring Systems APSR2 (2.0)2016‑10‑06 13:12:00
2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA Reference2005‑09‑07
RelationshipSpecialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 (2014‑05‑14 17:09:54)
Example
example for use case #1
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.4.3"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_ICDO"/>  <code code="31205-8" codeSystem="2.16.840.1.113883.6.1" displayName="Histology ICD-O-3 Cancer"/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="201001041405-0500"/>  </effectiveTime>
  <value xsi:type="CD" code="8500/3" codeSystem="2.16.840.1.113883.6.43.1"/>  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->
  </author>
  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 1..* R -->
  <specimen typeCode="SPC">
    <specimenRole classCode="SPEC">
      <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_slide_A1_HE"/>    </specimenRole>
  </specimen>
  <entryRelationship typeCode="SPRT">
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.38 'ICD-O-3 Behavior' (2015-12-03T09:11:54), not used in use case #1 -->
  </entryRelationship>
  <entryRelationship typeCode="SPRT">
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.39 'ICD-O-3 Differentiation' (2015-12-09T17:12:30) -->
  </entryRelationship>
  <entryRelationship typeCode="COMP">
    <!-- template 1.3.6.1.4.1.19376.1.3.10.4.4 'Assessment Scales Observation for Scoring Systems APSR2' (2016-10-06T13:12:00) -->
  </entryRelationship>
  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
  </reference>
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … 1RFirst four digits of Morphology axis code. A complete code consists of 6 digits (for morphology, behavior and grading), the latter both separated by "/" after the 4th digit in morphology.

Behavior and differentiation are coded as sub-observations
PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.4.3
Treetree.pnghl7:id
II0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
Treetree.pnghl7:code
CV (extensible)1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
 CONF
@code shall be "31205-8"
@codeSystem shall be "2.16.840.1.113883.6.1"
@codeSystemName shall be "LOINC"
@displayName shall be "Histology ICD-O-3 Cancer"
or
@code shall be "397005006"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SNOMED-CT"
@displayName shall be "WHO tumor classification (observable entity)"
Treetree.pnghl7:statusCode
CS (required)1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.2 (DYNAMIC)
Alert.pngError: Cannot find value set "1.3.6.1.4.1.19376.1.3.11.2"
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
Treetree.pnghl7:value
CD1 … 1RFirst four digits of Morphology axis codePaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.33 ICD-O-3 Morphology (2015‑11‑13 14:08:46)
 Example
for use case #1: invasive breast cancer, NST, well differentiated
<value xsi:type="CD" code="8500" codeSystem="2.16.840.1.113883.6.43.1"/>
Treetree.pnghl7:performer
II0 … 1CPerforming lab


Source: PaLM TF-3: 6.3.2.20



Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)
PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
Treetree.pnghl7:author
II0 … 1CContains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
Treeblank.png where [hl7:author [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.2']]]
Treetree.pnghl7:informant
II0 … *RInformant


Source: PaLM TF Suppl. APSR 2.0-3 : 6.3.6.5



Contains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (2016‑07‑08 11:22:58)
PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.6']]
Treetree.pnghl7:participant
II0 … *RAdditional participants


Source: PaLM TF Suppl. APSR 2.0-3 : 6.3.6.6



Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry APSR (Body) (2016‑07‑12 18:44:06)
PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.7']]
Included1 … *R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Treetree.pnghl7:specimen
1 … *RRequired in XD-LAB when more than one specimen is documented at this level. Always required in APSR.
PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreetree.png@typeCode
cs0 … 1FSPC
Treeblank.pngTreetree.pnghl7:specimenRole
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FSPEC
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treetree.pnghl7:entryRelationship
1 … 1R5th digit in the morphology axis code
Contains 1.3.6.1.4.1.19376.1.3.10.9.38 ICD-O-3 Behavior (2015‑12‑03 09:11:54)
PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.38']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treetree.pnghl7:entryRelationship
0 … 1R6th digit in the morphology axis code
Contains 1.3.6.1.4.1.19376.1.3.10.9.39 ICD-O-3 Differentiation (2015‑12‑09 17:12:30)
PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.39']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treetree.pnghl7:entryRelationship
0 … 1Roptional grading by a scoring system, e.g. by means of the Elston-Ellis-Scoring-System in case of invasive breast cancer (ICD-O C50)

Contains 1.3.6.1.4.1.19376.1.3.10.4.4 Assessment Scales Observation for Scoring Systems APSR2 (2016‑10‑06 13:12:00)
PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3
Treeblank.png where [@typeCode='COMP'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.4.4']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7:reference
0 … *RContains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)PaLM Suppl. APSR 2.0‑3: 6.3.6.11 ICD‑O‑3

6.3.6.12 Assessment Scales for Scoring systems - 1.3.6.1.4.1.19376.1.3.10.4.4

6.3.6.12.1 Definition and purpose

The Assessment Scales <entry> Content Modul contains in machine-readable form all the information concerning (semi)quantitative scoring systems often used for describing a tumor grading for a problem investigated. It is a constraint version of an AP Generic observation <entry> Content Module. It is usable within the ICD-O-3 Typing and Grading <entry> or within a Problem Organizer <entry> Content Module.

This Content Module structures the machine-readable data, which characterize the grading components of a tumor or a systemic disease according specific regulations.

6.2.6.14.1-1.jpg

Figure 6.3.6.12.1-1 CDA-RMIM of an Assessment Scales <entry>

6.3.6.12.2 Specification and Example
Id1.3.6.1.4.1.19376.1.3.10.4.4Effective Date valid from 2016‑10‑06 13:12:00

There are versions of templates with this id:
  • AssessmentScalesObservationScoringSystemsAPSR as of 2016‑10‑06 13:12:00
  • AssessmentScalesScoringSystemsAPSR as of 2016‑10‑06 12:36:29
  • CDASupplyContainerAPSR2 as of 2016‑07‑29
StatusKyellow.png DraftVersion Label2.0
NameAssessmentScalesObservationScoringSystemsAPSRDisplay NameAssessment Scales Observation for Scoring Systems APSR2
Description
Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF)

Assessment scale observation for Scoring Systems, e.g. Nottingham- (Elston-Ellis-) Grading for invasive breast cancers, describing the summarized scale value
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.4
LabelPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
ClassificationCDA Entry Level Template
Open/ClosedClosed (only defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 7 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.3.10.4.3ContainmentKyellow.png ICD-O-3 Typing and Grading Observation (2.0)2015‑11‑29 17:03:18
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png CDA Informant(Header&Body) APSR2 (2.0)2016‑07‑08 11:22:58
1.3.6.1.4.1.19376.1.8.1.4.7ContainmentKyellow.png Additional participant in an entry APSR (Body)2016‑07‑12 18:44:06
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.3.10.9.42ContainmentKyellow.png Assessment Scoring System APSR 2.0 (2.0)2016‑10‑10 11:33:36
2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA Reference2005‑09‑07
RelationshipSpecialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 (2014‑05‑14 17:09:54)
Example
example for use case #1, ER-Allred Score
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.4.4"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="273249006" codeSystem="2.16.840.1.113883.6.96" displayName="Assessment scales"/>  <derivationExpr text="sum"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20170711113628"/>  </effectiveTime>
  <priorityCode code="R" displayName="routine" codeSystem="2.16.840.1.113883.5.7"/>  <repeatNumber/>  <value xsi:type="PQ" value="8"/>  <interpretationCode code="RR" displayName="Reactive" codeSystem="2.16.840.1.113883.5.83"/>  <methodCode code="0114" codeSystem="2.16.840.1.113883.1.11.14079" displayName="Microscopy, Light"/>  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->
  </performer>
  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->
  </author>
  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->
  </informant>
  <participant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (2016-07-12T18:44:06) -->
  </participant>
  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 0..* R -->
  <entryRelationship typeCode="SPRT">
    <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.42 'Assessment Scoring System APSR 2.0' (2016-10-10T11:33:36) -->
  </entryRelationship>
  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
  </reference>
  <referenceRange typeCode="REFV">
    <observationRange classCode="OBS" moodCode="EVN.CRT">
      <code code="--code--" codeSystem="2.16.840.1.113883.5.4"/>      <text/>      <value xsi:type="ANY"/>      <interpretationCode code="CAR" displayName="Carrier" codeSystem="2.16.840.1.113883.5.83"/>    </observationRange>
  </referenceRange>
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treetree.png@classCode
cs0 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.4.4
Treetree.pnghl7:id
II0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treetree.pnghl7:code
CE (extensible)1 … 1MAssessment scale, e.g. grading by scoringPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
 CONF
@code shall be "273249006"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SCT"
@displayName shall be "Assessment scales"
or
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.19918 ActCoverageAssessmentObservationValue (2014‑03‑26)
 Example
for use case #1
<code code="273249006" codeSystem="2.16.840.1.113883.6.96" displayName="Assessment scales (assessment scale)"/>
Treetree.pnghl7:derivationExpr
ST0 … 1RThis optional field can be used to specify how the total score is calculated. In most cases the total score will be the sum of its components. But complex mathematical functions and/or logical operations are possible as well.
PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treetree.pnghl7:text
ED0 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
 Example
for use case #1
<text>Nottingham combined grad I (1 of 3)</text>
Treetree.pnghl7:statusCode
CS1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
 ConstraintThe observation statusCode is “

completed ” if the observation was actually performed and has produced a result in the  value  element. In other cases the status of the intended observation is “ aborted ” and the result will never come.


 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (2014‑03‑26)
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treetree.pnghl7:value
ANY1 … *Rany total value of a scoring systems, e.g. Gleason score, van Nuys score, etc., either with data type INT or with data type CD or CO 
PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
 Example
for use case #1, Nottingham combined grade I
<value value="1"/>
Treetree.pnghl7:interpretationCode
CE0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)
Treetree.pnghl7:methodCode
CE0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.pngTreetree.png@code
CONF0 … 1F0114
Treeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.1.11.14079
Treeblank.pngTreetree.png@codeSystemName
0 … 1FHL7
Treeblank.pngTreetree.png@displayName
0 … 1FMicroscopy, Light
Treetree.pnghl7:performer
II0 … 1CPerforming lab


Source: PaLM TF-3: 6.3.2.20



Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)
PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']]
 ConstraintThe performing laboratory is present at this level only if this particular observation was performed by a (subcontractor) laboratory distinct from the one issuing the rest of the observations in this organizer.
Treetree.pnghl7:author
II0 … *CAuthor


   Source: PaLM TF Suppl. APSR 2.0-3:
    6.3.6.2

Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.png where [hl7:author [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.2']]]
Treetree.pnghl7:informant
II0 … *RInformant


Source: PaLM TF Suppl. APSR 2.0-3 : 6.3.6.5



Contains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (2016‑07‑08 11:22:58)
PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.6']]
Treetree.pnghl7:participant
II0 … *RAdditional participants


Source: PaLM TF Suppl. APSR 2.0-3 : 6.3.6.6



Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry APSR (Body) (2016‑07‑12 18:44:06)
PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.png where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.7']]
Included0 … *R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Treetree.pnghl7:specimen
0 … *RRequired in XD-LAB when more than one specimen is documented at this level. Always required in APSR.
PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreetree.png@typeCode
cs0 … 1FSPC
Treeblank.pngTreetree.pnghl7:specimenRole
1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FSPEC
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
Treetree.pnghl7:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.10.9.42 Assessment Scoring System APSR 2.0 (2016‑10‑10 11:33:36)PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.png where [@typeCode='SPRT'] [hl7:observation [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.9.42']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treetree.pnghl7:reference
0 … *RContains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treetree.pnghl7:referenceRange
0 … *RPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFV
Treeblank.pngTreetree.pnghl7:observationRange
1 … 1RPaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FOBS
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs0 … 1FEVN.CRT
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CD0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.5.4 (Act Code)
Treeblank.pngTreeblank.pngTreetree.pnghl7:text
ED0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
ANY0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretationCode
CE0 … 1PaLM Suppl. APSR 2.0‑3: 6.3.6.12 Assessment scales
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)

VOLUME 4 - VALUE SETS

1 Introduction

1.1 Overview of IHE

1.2 Overview of the PaLM Technical Framework

1.3 Audience

1.4 Relationship to Standards

1.5 Relationship to Real-World Architectures

1.6 Comments

1.7 Copyright Permissions

1.8 IHE TF Development and Maintenance Process

1.9 Glossary

2 Overview

3 Open Issues

4 APSR Value Sets

4.1 Generic AP Observation Codes 1.3.6.1.4.1.19376.1.3.11.11

Id1.3.6.1.4.1.19376.1.3.11.11Effective Date valid from 2015‑11‑22 12:20:34
StatusKyellow.png DraftVersion Label
NameAP-ObservationDisplay NameAP Observation
DescriptionGeneric codes for AP Observations of all kind, including results of ancillary techniques (immunohistochemistry, in-situ-hybridization, other molecular methods)
CopyrightThis artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.
A valid code from one of the 12 code systems:
Code System NameCode System IdCode System VersionFlexibility
 Logical Observation Identifier Names and Codes2.16.840.1.113883.6.1 DYNAMIC
 SNOMED Clinical Terms2.16.840.1.113883.6.96 DYNAMIC
 International Classification of Diseases for Oncology, version 3.2.16.840.1.113883.6.43.1 DYNAMIC
 ICD102.16.840.1.113883.6.3 DYNAMIC
 TNM Edition8 UICC2.16.840.1.113883.15.16 DYNAMIC
 TNM Edition7 UICC2.16.840.1.113883.15.6 DYNAMIC
 TNM Edition6 UICC2.16.840.1.113883.15.7 DYNAMIC
 TNM Edition5 UICC2.16.840.1.113883.15.8 DYNAMIC
 Unified Code for Units of Measure2.16.840.1.113883.6.8 DYNAMIC
 Online Mendelian Inheritance in Man 19932.16.840.1.113883.6.174 DYNAMIC
 DKG Coding scheme1.2.276.0.76.3.1.131.1.5.1 DYNAMIC
 localization codes for distant metastases1.2.276.0.76.5.401 DYNAMIC

4.2 Problem type 1.3.6.1.4.1.19376.1.3.11.7

Id1.3.6.1.4.1.19376.1.3.11.7Effective Date valid from 2016‑07‑11 09:52:19
StatusKyellow.png DraftVersion Label
NameProblemTypeDisplay NameProblem Type
DescriptionValues for the problem under investigation
CopyrightThis artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.
A valid code from the code system:
Code System NameCode System IdCode System Version
 ICD102.16.840.1.113883.6.3
Or one of the following:
4 Source Code Systems
2.16.840.1.113883.6.3 - ICD10
2.16.840.1.113883.6.96 - SNOMED Clinical Terms
2.16.840.1.113883.5.6 - ActClass
2.16.840.1.113883.5.1008 - Null Flavor
Level/ TypeCodeDisplay NameCode System
0‑L
115597007
Description of specimen character (procedure)
SNOMED Clinical Terms
0‑L
128462008
Secondary malignant neoplastic disease (disorder)
SNOMED Clinical Terms
0‑L
367651003
Malignant neoplasm of primary, secondary, or uncertain origin (morphologic abnormality)
SNOMED Clinical Terms
0‑L
SPCOBS
specimen observation
ActClass
0‑L
3898006
Neoplasm, benign (morphologic abnormality)
SNOMED Clinical Terms
0‑L
109355002
Carcinoma in situ (disorder)
SNOMED Clinical Terms
0‑L
23583003
Inflammation (morphologic abnormality)
SNOMED Clinical Terms
0‑L
33359002
Degeneration (morphologic abnormality)
SNOMED Clinical Terms
0‑L
49601007
Disorder of cardiovascular system (disorder)
SNOMED Clinical Terms
0‑L
ASKU
asked but unknown
Null Flavor

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

4.3 Container Entity Class Type 1.3.6.1.4.1.19376.1.3.11.8

Id1.3.6.1.4.1.19376.1.3.11.8Effective Date valid from 2016‑09‑08 11:55:11
StatusKyellow.png DraftVersion Label
NameContainerEntityClassTypePaLMDisplay NameContainerEntityClassTypePaLM
DescriptionTypes of Containers and their additives in Anatomic Pathology
CopyrightThis artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.
2 Source Code Systems
2.16.840.1.113883.6.96 - SNOMED Clinical Terms
1.2.840.10008.2.16.4 - DICOM Controlled Terminology
Level/ TypeCodeDisplay NameCode System
0‑L
434746001
Specimen vial (physical object)
SNOMED Clinical Terms
0‑L
434464009
Tissue cassette (physical object)
SNOMED Clinical Terms
0‑L
434708008
Tissue cassette for microarray (physical object)
SNOMED Clinical Terms
0‑L
433466003
Microscope slide (physical object)
SNOMED Clinical Terms
0‑S
433453003
Specimen container component (physical object)
SNOMED Clinical Terms
1‑S
430863003
Tissue embedding medium (substance)
SNOMED Clinical Terms
2‑L
311731000
Paraffin wax (substance)
SNOMED Clinical Terms
2‑L
433469005
Frozen section embedding medium (substance)
SNOMED Clinical Terms
2‑L
61088005
Plastic (substance)
SNOMED Clinical Terms
2‑L
10249006
Agar (substance)
SNOMED Clinical Terms
2‑L
65345002
Epoxy resin (substance)
SNOMED Clinical Terms
2‑L
427811002
Polymethyl methacrylate (substance)
SNOMED Clinical Terms
1‑L
433472003
Microscope slide coverslip (physical object)
SNOMED Clinical Terms
1‑L
430862008
Microscope slide mounting medium (substance)
SNOMED Clinical Terms
0‑S
CID8101
Container type
DICOM Controlled Terminology
1‑L
A-01024
Specimen vial
DICOM Controlled Terminology
1‑L
A-0101B
Microscope slide
DICOM Controlled Terminology
1‑L
A-01023
Specimen container
DICOM Controlled Terminology
1‑L
A-01021
Electron microscopy grid
DICOM Controlled Terminology
1‑L
A-01025
Specimen well
DICOM Controlled Terminology
0‑S
CID8114
Fixatives
DICOM Controlled Terminology
0‑S
CID8102
Container Component Types
DICOM Controlled Terminology
0‑S
CID8115
Specimen Embedding Media
DICOM Controlled Terminology

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

4.4 Procedure (target) site 1.3.6.1.4.1.19376.1.3.11.9

Id1.3.6.1.4.1.19376.1.3.11.9Effective Date valid from 2016‑06‑01 18:46:15
StatusKyellow.png DraftVersion Label
NameProcedureSiteDisplay NameProcedure Site
DescriptionTarget sites of specimen processing procedures
CopyrightThis artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.
2 Source Code Systems
2.16.840.1.113883.6.96 - SNOMED Clinical Terms
1.2.840.10008.2.16.4 - DICOM Controlled Terminology
Level/ TypeCodeDisplay NameCode SystemDescription
0‑L
309050000
Body substance sample
SNOMED Clinical Termsall children of "Body substance sample"
0‑L
309051001
Body fluid sample
SNOMED Clinical Terms
0‑S
430856003
Tissue section (specimen)
SNOMED Clinical Terms
1‑L
441652008
Formalin-fixed paraffin-embedded tissue specimen
SNOMED Clinical Terms
1‑L
16214131000119104
Frozen tissue section sample (specimen)
SNOMED Clinical Terms
0‑S
CID8103
Anatomic Pathology Specimen Types
DICOM Controlled Terminology
1‑L
G-843A
Gross specimen
DICOM Controlled Terminology
1‑L
G-843B
Core sample of tissue block
DICOM Controlled Terminology
1‑L
G-843C
Tissue spot
DICOM Controlled Terminology
1‑L
G-803C
Smear sample
DICOM Controlled Terminology
1‑L
T-1A404
Touch preparation cytologic material
DICOM Controlled Terminology
1‑L
T-1A403
Liquid based cytologic material
DICOM Controlled Terminology
1‑L
G-8003
Aspirate
DICOM Controlled Terminology
0‑L
48469005
Cytologic material (specimen)
SNOMED Clinical Terms

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

4.5 Specimen collection and processing 1.3.6.1.4.1.19376.1.3.11.10

Id1.3.6.1.4.1.19376.1.3.11.10Effective Date valid from 2016‑05‑31 15:09:59
StatusKyellow.png DraftVersion Label
NameSpecimenCollectionAndProcessingDisplay NameSpecimen Collection and Processing
DescriptionMixed Value set for Specimen collection and Processing
CopyrightThis artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.
5 Source Code Systems
2.16.840.1.113883.5.6 - ActClass
2.16.840.1.113883.6.96 - SNOMED Clinical Terms
1.2.276.0.76.5.464
1.2.840.10008.2.16.4 - DICOM Controlled Terminology
2.16.840.1.113883.6.4 - International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)
Level/ TypeCodeDisplay NameCode SystemDesignations
0‑S
SPECCOLLECT
Specimen collection
ActClass
1‑S
17636008
Specimen collection (procedure)
SNOMED Clinical Terms
2‑L
48635004
Fine needle biopsy (procedure)
SNOMED Clinical Terms
2‑S
86273004
Biopsy (procedure)
SNOMED Clinical Terms
3‑L
439336003
Brush biopsy (procedure)
SNOMED Clinical Terms
3‑L
53767003
Endoscopic biopsy (procedure)
SNOMED Clinical Terms
3‑L
8889005
Excisional biopsy (procedure)
SNOMED Clinical Terms
3‑S
277590007
Imaging guided biopsy (procedure)
SNOMED Clinical Terms
4‑L
442787002
Fine needle aspiration biopsy using imaging guidance (procedure)
SNOMED Clinical Terms
4‑L
277592004
Magnetic resonance imaging guided biopsy (procedure)
SNOMED Clinical Terms
4‑L
277667006
Ultrasound guided biopsy (procedure)
SNOMED Clinical Terms
4‑L
277666002
X-ray guided biopsy (procedure)
SNOMED Clinical Terms
3‑L
45681003
Staging operation involving incision, exploration and biopsy (procedure)
SNOMED Clinical Terms
3‑L
70871006
Incisional biopsy (procedure)
SNOMED Clinical Terms
3‑L
129249002
Needle biopsy (procedure)
SNOMED Clinical Terms
3‑L
119283008
Open biopsy (procedure)
SNOMED Clinical Terms
3‑L
68660007
Punch biopsy (procedure)
SNOMED Clinical Terms
3‑L
72342005
Shave biopsy (procedure)
SNOMED Clinical Terms
3‑L
274330002
Surgical biopsy (procedure)
SNOMED Clinical Terms
3‑L
50590007
Trephine biopsy (procedure)
SNOMED Clinical Terms
2‑S
65801008
Excision (procedure)
SNOMED Clinical Terms
3‑L
81723002
Amputation (procedure)
SNOMED Clinical Terms
3‑L
86743009
Local excision (procedure)
SNOMED Clinical Terms
3‑L
125571002
Lobectomy (procedure)
SNOMED Clinical Terms
3‑L
26007001
Hemi-excision (procedure)
SNOMED Clinical Terms
3‑L
38829003
Partial excision (procedure)
SNOMED Clinical Terms
3‑L
89540006
Segmental excision and ligation (procedure)
SNOMED Clinical Terms
3‑L
65854006
Reexcision (procedure)
SNOMED Clinical Terms
3‑S
62141006
Radical excision (procedure)
SNOMED Clinical Terms
4‑L
88088007
Radical excision with lymph node dissection (procedure)
SNOMED Clinical Terms
3‑L
79095000
Complete excision of organ (procedure)
SNOMED Clinical Terms
3‑L
370612006
Excision of neoplasm (procedure)
SNOMED Clinical Terms
3‑L
20418004
Wedge resection (procedure)
SNOMED Clinical Terms
2‑L
56757003
Scraping (procedure)
SNOMED Clinical Terms
1‑L
1-40...1-49
Biopsies without incision
1.2.276.0.76.5.464
1‑L
1-50...1-58
Biopsies with incision
1.2.276.0.76.5.464
1‑L
5-01...5-09
Surgical measures
1.2.276.0.76.5.464
1‑L
1-10...1-99
Diagnostic measures
1.2.276.0.76.5.464
1‑S
CID8109
all children of Specimen Collection Procedure
DICOM Controlled Terminology
1‑S
00...0Y
all children of 0
International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)
0‑S
SPCTRT
Specimen treatment
ActClass
1‑S
CID8110
all children of Specimen Sampling Procedures
DICOM Controlled Terminology
1‑S
CID8111
all children of Specimen Preparation Procedure
DICOM Controlled Terminology
1‑S
CID8112
all children of Specimen Stains
DICOM Controlled Terminology
1‑S
CID8113
all children of Specimen Preparation Steps
DICOM Controlled Terminology
1‑S
CID8114
all children of Specimen Fixatives
DICOM Controlled Terminology
1‑S
9265001
Specimen processing (procedure)
SNOMED Clinical Terms
2‑L
430854000
Touch preparation of specimen (procedure)
SNOMED Clinical Terms
2‑L
448938001
Preparation of smear (procedure)
SNOMED Clinical Terms
2‑L
77896007
Cytopathology procedure, cell block and smear preparation (procedure)
SNOMED Clinical Terms
2‑L
4064007
Specimen aliquoting (procedure)
SNOMED Clinical Terms
2‑L
8378006
Trimming (procedure)
SNOMED Clinical Terms
2‑L
73373003
Specimen centrifugation (procedure)
SNOMED Clinical Terms
2‑L
27872000
Specimen freezing (procedure)
SNOMED Clinical Terms
2‑L
104166004
Nucleic acid molecular isolation or extraction method (procedure)
SNOMED Clinical Terms
2‑S
13283003
Tissue processing technique (procedure)
SNOMED Clinical Terms
3‑L
27204007
Tissue frozen section technique, complete (procedure)
SNOMED Clinical Terms
3‑L
40923002
Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)
SNOMED Clinical Terms
4‑L
434472006
Sectioning of tissue block (procedure)
SNOMED Clinical Terms
4‑L
434475008
Step sectioning of tissue block (procedure)
SNOMED Clinical Terms
4‑L
434474007
Surface recutting of tissue block (procedure)
SNOMED Clinical Terms
4‑L
434479002
Core sampling of tissue block (procedure)
SNOMED Clinical Terms
4‑L
433454009
Microdissection of tissue specimen using laser (procedure)
SNOMED Clinical Terms
4‑L
702941008
Paraffin embedding (qualifier value)
SNOMED Clinical Terms
2‑S
127790008
Staining method (procedure)
SNOMED Clinical Terms
3‑L
406792001
Acid phosphatase stain method (procedure)
SNOMED Clinical Terms
3‑L
406901007
Neutrophil alkaline phosphatase stain method (procedure)
SNOMED Clinical Terms
3‑L
406902000
New fuchsin stain method (procedure)
SNOMED Clinical Terms
3‑L
406903005
Nile blue stain method (procedure)
SNOMED Clinical Terms
3‑L
406904004
Nitrazine yellow stain method (procedure)
SNOMED Clinical Terms
3‑L
117229004
Nonspecific esterase stain method (procedure)
SNOMED Clinical Terms
3‑L
406905003
Nuclear fast red stain method (procedure)
SNOMED Clinical Terms
3‑L
406906002
Orange G stain method (procedure)
SNOMED Clinical Terms
3‑L
406907006
Orange II stain method (procedure)
SNOMED Clinical Terms
3‑L
406908001
Page blue 83 stain method (procedure)
SNOMED Clinical Terms
3‑L
406909009
Page blue G-90 stain method (procedure)
SNOMED Clinical Terms
3‑L
406910004
Patent blue V sodium salt stain method (procedure)
SNOMED Clinical Terms
3‑L
406911000
Permethrin stain method (procedure)
SNOMED Clinical Terms
3‑L
406912007
Phloxin B stain method (procedure)
SNOMED Clinical Terms
3‑L
406913002
Ponceau 3R stain method (procedure)
SNOMED Clinical Terms
3‑L
406914008
Ponceau S stain method (procedure)
SNOMED Clinical Terms
3‑L
406915009
Ponceau xylidine stain method (procedure)
SNOMED Clinical Terms
3‑L
406916005
Pontamine sky blue 5BX stain method (procedure)
SNOMED Clinical Terms
3‑L
406900008
Naphthol yellow S stain method (procedure)
SNOMED Clinical Terms
3‑L
406899003
Naphthol green B stain method (procedure)
SNOMED Clinical Terms
3‑L
406898006
Naphthalene black 12B stain method (procedure)
SNOMED Clinical Terms
3‑L
117306005
Lawson-Van Gieson stain method (procedure)
SNOMED Clinical Terms
3‑L
406875003
Leishman stain method (procedure)
SNOMED Clinical Terms
3‑L
406876002
Light green SF stain method (procedure)
SNOMED Clinical Terms
3‑L
406877006
Lissamine fast red B stain method (procedure)
SNOMED Clinical Terms
3‑L
406878001
Lissamine fast yellow stain method (procedure)
SNOMED Clinical Terms
3‑L
406880007
Lissamine rhodamine stain method (procedure)
SNOMED Clinical Terms
3‑L
398507009
Malachite green stain method (procedure)
SNOMED Clinical Terms
3‑L
117218003
Mallory bleach stain method (procedure)
SNOMED Clinical Terms
3‑L
406890004
Martius yellow stain method (procedure)
SNOMED Clinical Terms
3‑L
406891000
Meldola blue stain method (procedure)
SNOMED Clinical Terms
3‑L
406892007
Metanil yellow stain method (procedure)
SNOMED Clinical Terms
3‑L
406893002
Methyl blue stain method (procedure)
SNOMED Clinical Terms
3‑L
406894008
Methyl orange stain method (procedure)
SNOMED Clinical Terms
3‑L
406895009
Methyl red stain method (procedure)
SNOMED Clinical Terms
3‑L
406896005
Methylene blue stain method (procedure)
SNOMED Clinical Terms
3‑L
406897001
Methylene violet stain (Bernthsen) method (procedure)
SNOMED Clinical Terms
3‑L
37926009
Microbial stain method (procedure)
SNOMED Clinical Terms
3‑L
406917001
Pontamine sky blue 6BX stain method (procedure)
SNOMED Clinical Terms
3‑L
406918006
Procion brilliant blue MRS stain method (procedure)
SNOMED Clinical Terms
3‑L
117326009
Quinacrine fluorescent stain method (procedure)
SNOMED Clinical Terms
3‑L
406936006
Sudan blue stain method (procedure)
SNOMED Clinical Terms
3‑L
406937002
Sunset yellow FCF stain method (procedure)
SNOMED Clinical Terms
3‑L
117031001
Supravital stain method (procedure)
SNOMED Clinical Terms
3‑L
406938007
Tartrazine stain method (procedure)
SNOMED Clinical Terms
3‑L
406939004
Thioflavine T stain method (procedure)
SNOMED Clinical Terms
3‑L
406940002
Thionine stain method (procedure)
SNOMED Clinical Terms
3‑L
406941003
Titan yellow stain method (procedure)
SNOMED Clinical Terms
3‑L
406942005
Tropaeolin O stain method (procedure)
SNOMED Clinical Terms
3‑L
406943000
Tropaeolin OO stain method (procedure)
SNOMED Clinical Terms
3‑L
406944006
Trypan blue stain method (procedure)
SNOMED Clinical Terms
3‑L
406945007
Vital new red stain method (procedure)
SNOMED Clinical Terms
3‑L
104249006
Vital stain method (procedure)
SNOMED Clinical Terms
3‑L
406946008
Water soluble aniline blue stain method (procedure)
SNOMED Clinical Terms
3‑L
406948009
Water soluble anthracene brown stain method (procedure)
SNOMED Clinical Terms
3‑L
406947004
Water soluble nigrosine stain method (procedure)
SNOMED Clinical Terms
3‑L
406949001
Waxoline blue stain method (procedure)
SNOMED Clinical Terms
3‑L
406950001
Xylene cyanol FF stain method (procedure)
SNOMED Clinical Terms
3‑L
406934009
Sudan black stain method (procedure)
SNOMED Clinical Terms
3‑L
406935005
Sudan black B stain method (procedure)
SNOMED Clinical Terms
3‑L
117030000
Sudan IV stain method (procedure)
SNOMED Clinical Terms
3‑L
406919003
Romanowsky stain method (procedure)
SNOMED Clinical Terms
3‑L
406920009
Rose bengal stain method (procedure)
SNOMED Clinical Terms
3‑L
406921008
Rosolic acid sodium salt stain method (procedure)
SNOMED Clinical Terms
3‑L
406922001
Saffron stain method (procedure)
SNOMED Clinical Terms
3‑L
117330007
Schmorl stain method (procedure)
SNOMED Clinical Terms
3‑L
117041003
Silver stain method (procedure)
SNOMED Clinical Terms
3‑L
406924000
Sirius red F3B stain method (procedure)
SNOMED Clinical Terms
3‑L
406925004
Solochrome azurine (BS) stain method (procedure)
SNOMED Clinical Terms
3‑L
406926003
Solochrome black 6B stain method (procedure)
SNOMED Clinical Terms
3‑L
406927007
Solochrome cyanine R stain method (procedure)
SNOMED Clinical Terms
3‑L
406928002
Solochrome dark blue stain method (procedure)
SNOMED Clinical Terms
3‑L
406929005
Soluble berlin blue stain method (procedure)
SNOMED Clinical Terms
3‑L
406930000
Spirit soluble aniline blue stain method (procedure)
SNOMED Clinical Terms
3‑L
406931001
Spirit soluble eosin stain method (procedure)
SNOMED Clinical Terms
3‑L
406932008
Spore stain method (procedure)
SNOMED Clinical Terms
3‑L
406933003
Sudan II stain method (procedure)
SNOMED Clinical Terms
3‑L
117029005
Sudan III stain method (procedure)
SNOMED Clinical Terms
3‑L
406874004
Lacmoid stain method (procedure)
SNOMED Clinical Terms
3‑L
406873005
Kenacid blue R stain method (procedure)
SNOMED Clinical Terms
3‑L
406818007
Bismark brown Y stain method (procedure)
SNOMED Clinical Terms
3‑L
406819004
Blue shade eosin stain method (procedure)
SNOMED Clinical Terms
3‑L
406820005
Brazilin stain method (procedure)
SNOMED Clinical Terms
3‑L
406821009
Brilliant cresyl blue stain method (procedure)
SNOMED Clinical Terms
3‑L
406822002
Brilliant crocein stain method (procedure)
SNOMED Clinical Terms
3‑L
406823007
Brilliant orange stain method (procedure)
SNOMED Clinical Terms
3‑L
406824001
Brilliant yellow stain method (procedure)
SNOMED Clinical Terms
3‑L
77281003
Calcofluor white stain (procedure)
SNOMED Clinical Terms
3‑L
406825000
Carminic acid stain method (procedure)
SNOMED Clinical Terms
3‑L
406826004
Carmoisine A stain method (procedure)
SNOMED Clinical Terms
3‑L
406827008
Celestine blue B stain method (procedure)
SNOMED Clinical Terms
3‑L
406828003
Chloroacetate esterase stain method (procedure)
SNOMED Clinical Terms
3‑L
406830001
Chromotrope 2R stain method (procedure)
SNOMED Clinical Terms
3‑L
406831002
Chrysoidine R stain method (procedure)
SNOMED Clinical Terms
3‑L
406832009
Chrysoidine Y stain method (procedure)
SNOMED Clinical Terms
3‑L
406833004
Cochineal stain method (procedure)
SNOMED Clinical Terms
3‑L
117055006
Congo red stain method (procedure)
SNOMED Clinical Terms
3‑L
406817002
Bismark brown R stain method (procedure)
SNOMED Clinical Terms
3‑L
406816006
Biebrich scarlet stain method (procedure)
SNOMED Clinical Terms
3‑L
406815005
Beta-glucuronidase stain method (procedure)
SNOMED Clinical Terms
3‑L
406793006
Albert's stain method (procedure)
SNOMED Clinical Terms
3‑L
117036006
Alcian blue stain method (procedure)
SNOMED Clinical Terms
3‑L
406794000
Alcohol soluble nigrosine stain method (procedure)
SNOMED Clinical Terms
3‑L
406795004
Alizarin blue S stain method (procedure)
SNOMED Clinical Terms
3‑L
406796003
Alizarin cyanine green stain method (procedure)
SNOMED Clinical Terms
3‑L
406797007
Alizarin red S stain method (procedure)
SNOMED Clinical Terms
3‑L
406798002
Alizarin yellow GG stain method (procedure)
SNOMED Clinical Terms
3‑L
406799005
Alizarin yellow R stain method (procedure)
SNOMED Clinical Terms
3‑L
406800009
Auramine stain method (procedure)
SNOMED Clinical Terms
3‑L
406801008
Azo black stain method (procedure)
SNOMED Clinical Terms
3‑L
406802001
Azocarmine G (GX) stain method (procedure)
SNOMED Clinical Terms
3‑L
406803006
Azophloxin stain method (procedure)
SNOMED Clinical Terms
3‑L
406804000
Azorubin S stain method (procedure)
SNOMED Clinical Terms
3‑L
406811001
Azure A stain method (procedure)
SNOMED Clinical Terms
3‑L
406812008
Azure B stain method (procedure)
SNOMED Clinical Terms
3‑L
406813003
Azure C stain method (procedure)
SNOMED Clinical Terms
3‑L
406814009
Benzo fast scarlet stain method (procedure)
SNOMED Clinical Terms
3‑L
406835006
Crystal ponceau stain method (procedure)
SNOMED Clinical Terms
3‑L
406836007
Curcumin stain method (procedure)
SNOMED Clinical Terms
3‑L
117298004
Cytopathology staining method (procedure)
SNOMED Clinical Terms
3‑L
406857004
Flagellar stain method (procedure)
SNOMED Clinical Terms
3‑L
406858009
Fluorescent stain method (procedure)
SNOMED Clinical Terms
3‑L
406863008
Fuchsin acid stain method (procedure)
SNOMED Clinical Terms
3‑L
117047004
Fuchsin basic stain method (procedure)
SNOMED Clinical Terms
3‑L
20543007
Fungus stain method (procedure)
SNOMED Clinical Terms
3‑L
406864002
Gallocyanine stain method (procedure)
SNOMED Clinical Terms
3‑L
422329009
Hall's bilirubin stain (procedure)
SNOMED Clinical Terms
3‑L
406865001
Hematein stain method (procedure)
SNOMED Clinical Terms
3‑L
108256005
Hematology staining procedure (procedure)
SNOMED Clinical Terms
3‑L
406867009
Immunofluorescent stain method (procedure)
SNOMED Clinical Terms
3‑L
406868004
Indigo carmine stain method (procedure)
SNOMED Clinical Terms
3‑L
406869007
Indophenol from naphthol stain method (procedure)
SNOMED Clinical Terms
3‑L
406870008
Insoluble berlin blue stain method (procedure)
SNOMED Clinical Terms
3‑L
406871007
Janus green B stain method (procedure)
SNOMED Clinical Terms
3‑L
406872000
Jenner-Giemsa stain method (procedure)
SNOMED Clinical Terms
3‑L
406856008
Field's stain method (procedure)
SNOMED Clinical Terms
3‑L
406855007
Feulgen reaction stain method (procedure)
SNOMED Clinical Terms
3‑L
406854006
Fat red 7B stain method (procedure)
SNOMED Clinical Terms
3‑L
406837003
Diamond black stain method (procedure)
SNOMED Clinical Terms
3‑L
406838008
Durazol red stain method (procedure)
SNOMED Clinical Terms
3‑L
406839000
Erie garnet stain method (procedure)
SNOMED Clinical Terms
3‑L
406840003
Eriochrome blue black SE stain method (procedure)
SNOMED Clinical Terms
3‑L
406841004
Erythrosin B stain method (procedure)
SNOMED Clinical Terms
3‑L
406842006
Erythrosin Y stain method (procedure)
SNOMED Clinical Terms
3‑L
406843001
Evans blue stain method (procedure)
SNOMED Clinical Terms
3‑L
406844007
Fast blue B salt stain method (procedure)
SNOMED Clinical Terms
3‑L
406845008
Fast blue BB salt stain method (procedure)
SNOMED Clinical Terms
3‑L
406846009
Fast blue RR salt stain method (procedure)
SNOMED Clinical Terms
3‑L
406847000
Fast garnet GBC salt stain method (procedure)
SNOMED Clinical Terms
3‑L
406848005
Fast green FCF stain method (procedure)
SNOMED Clinical Terms
3‑L
406849002
Fast red B salt stain method (procedure)
SNOMED Clinical Terms
3‑L
406850002
Fast red ITR stain method (procedure)
SNOMED Clinical Terms
3‑L
406851003
Fast red TR salt stain method (procedure)
SNOMED Clinical Terms
3‑L
406852005
Fast sulfon black F stain method (procedure)
SNOMED Clinical Terms
3‑L
406853000
Fast violet B salt stain method (procedure)
SNOMED Clinical Terms
3‑L
406979008
Ziehl-Neelsen stain method (procedure)
SNOMED Clinical Terms
3‑S
104210008
Hematoxylin and eosin stain method (procedure)
SNOMED Clinical Terms
4‑L
117239005
Harris regressive hematoxylin and eosin stain method (procedure)
SNOMED Clinical Terms
4‑L
117240007
Mayers progressive hematoxylin and eosin stain method (procedure)
SNOMED Clinical Terms
3‑L
80246006
Special stain, blood or bone marrow, explain by report (procedure)
SNOMED Clinical Terms
3‑L
117617002
Immunohistochemistry procedure (procedure)
SNOMED Clinical Terms
3‑L
384715000
Nucleic acid hybridization procedure (procedure)
SNOMED Clinical Terms

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4.6 UICC/AJCC stage 1.3.6.1.4.1.19376.1.3.11.18

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4.7 UICC/AJCC T category 1.3.6.1.4.1.19376.1.3.11.15

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4.8 UICC/AJCC T category (SCT) 1.3.6.1.4.1.19376.1.3.11.12

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2 Source Code Systems
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T0 category (finding)
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23351008
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Tumor stage T1a (finding)
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Tumor stage T1a1 (finding)
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Tumor stage T1c (finding)
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T2 category (finding)
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261658003
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65565005
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261660001
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261661002
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TX category (finding)
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Asked but unknown
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4.9 UICC/AJCC N category 1.3.6.1.4.1.19376.1.3.11.16

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4.10 UICC/AJCC N category (SCT) 1.3.6.1.4.1.19376.1.3.11.13

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4.11 UICC/AJCC M category 1.3.6.1.4.1.19376.1.3.11.17

Id1.3.6.1.4.1.19376.1.3.11.17Effective Date valid from 2015‑11‑11 15:53:15
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4.12 UICC/AJCC M category (SCT) 1.3.6.1.4.1.19376.1.3.11.14

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CopyrightThis artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyright of the International Health Terminology Standards Development Organisation (IHTSDO). Implementers of these artefacts must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/getsnomed-ct or info@snomed.org.
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4.13 UICC/AJCC C-Factor 1.3.6.1.4.1.19376.1.3.11.19

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4.14 UICC/AJCC C-Factor (SCT) 1.3.6.1.4.1.19376.1.3.11.20

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84068000
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76321005
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44756004
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75800005
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59397002
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4.15 UICC/AJCC Residual tumor (R) classification 1.3.6.1.4.1.19376.1.3.11.21

Id1.3.6.1.4.1.19376.1.3.11.21Effective Date valid from 2015‑06‑25 11:23:51
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5 Source Code Systems
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Surgical circumferential margin is closest uninvolved margin to malignant neoplasm (finding)
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278271003
Residual tumor stage R1 (finding)
SNOMED Clinical Terms
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384620009
Surgical circumferential margin involved by malignant neoplasm (tumor present 0-1 mm from circumferential resection margin) (finding)
SNOMED Clinical Terms
0‑L
278272005
Residual tumor stage R2 (finding)
SNOMED Clinical Terms
0‑L
258253006
Residual tumor stage RX (finding)
SNOMED Clinical Terms
0‑L
RX
RX
TNM Edition8 UICC
0‑L
R0>1mm
R0 > 1mm
TNM Edition7 UICC
0‑L
R0<1mm
R0 < 1mm
TNM Edition7 UICC
0‑L
R1
R1
TNM Edition8 UICC
1‑L
R1-dir
R1-dir
TNM Edition7 UICC
1‑L
R1(is)
R1(is)
1.2.276.0.76.3.1.131.1.5.120
1‑L
R1(cy)
R1(cy)
1.2.276.0.76.3.1.131.1.5.120
0‑L
R2
R2
TNM Edition8 UICC
1‑L
R2a
R2a
TNM Edition7 UICC
1‑L
R2b
R2b
TNM Edition7 UICC
1‑L
R2c
R2c
TNM Edition7 UICC
0‑L
CRM+
CRM positive
TNM Edition7 UICC
0‑L
CRM-
CRM negative
TNM Edition7 UICC

0‑L
ASKU
Asked but unknown
Null Flavor
Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

4.16 UICC/AJCC clinical/pathological 1.3.6.1.4.1.19376.1.3.11.22

Id1.3.6.1.4.1.19376.1.3.11.22Effective Date valid from 2015‑11‑04 15:52:34
StatusKyellow.png DraftVersion Label
NameUICC-clinical-pathologicalDisplay NameUICC clinical/pathological
DescriptionQualifiers for each TNM category classifying the observation method and the time frame of observation in relation to treatment
3 Source Code Systems
2.16.840.1.113883.15.16 - TNM Edition8 UICC
1.2.276.0.76.11.9 - hl7de-valueset-9
2.16.840.1.113883.5.1008 - Null Flavor
Level/ TypeCodeDisplay NameCode SystemDescription
0‑L
p
p
TNM Edition8 UICCThe pathological assessment of the primary tumor entails a resection of the primary tumor or a biopsy adequate to evaluate the highest T category. The pathological assessment of the regional lymph nodes entails a removal of lymph nodes adequate to validate the absence of regional lymph node metastasis or sufficient to evaluate the highest pN category. The pathological assessment of distant metastasis entails microscopic examination.
0‑L
c
c
TNM Edition8 UICCThe clinical classification is based on evidence acquired before treatment
1‑L
u
u
hl7de-valueset-9The clinical classification is based on ultrasound evidence acquired before treatment
1‑L
ct
ct
hl7de-valueset-9The clinical classification is based on CT imaging evidence acquired before treatment
1‑L
mr
mr
hl7de-valueset-9The clinical classification is based on magnetic resonance imaging evidence acquired before treatment

0‑L
ASKU
Asked but unknown
Null Flavor
Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

4.17 UICC/AJCC Venous Invasion 1.3.6.1.4.1.19376.1.3.11.23

Id1.3.6.1.4.1.19376.1.3.11.23Effective Date valid from 2015‑11‑04 16:17:55
StatusKyellow.png DraftVersion Label
NameUICC-vene-invasionDisplay NameUICC Venous Invasion
DescriptionObservation for tumor spread coding the degree of venous invasion
2 Source Code Systems
2.16.840.1.113883.15.16 - TNM Edition8 UICC
2.16.840.1.113883.5.1008 - Null Flavor
Level/ TypeCodeDisplay NameCode System
0‑L
V0
V0
TNM Edition8 UICC
0‑L
V1
V1
TNM Edition8 UICC
0‑L
V2
V2
TNM Edition8 UICC
0‑L
VX
VX
TNM Edition8 UICC

0‑L
ASKU
Asked but unknown
Null Flavor
Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

4.18 UICC/AJCC Lymphatic Invasion 1.3.6.1.4.1.19376.1.3.11.24

Id1.3.6.1.4.1.19376.1.3.11.24Effective Date valid from 2015‑11‑04 16:19:20
StatusKyellow.png DraftVersion Label
NameUICC-lymphatic-invasionDisplay NameUICC Lymphatic Invasion
DescriptionObservation for tumor spread coding the degree of lymphatic invasion
2 Source Code Systems
2.16.840.1.113883.15.16 - TNM Edition8 UICC
2.16.840.1.113883.5.1008 - Null Flavor
Level/ TypeCodeDisplay NameCode System
0‑L
L0
L0
TNM Edition8 UICC
0‑L
L1
L1
TNM Edition8 UICC
0‑L
LX
LX
TNM Edition8 UICC

0‑L
ASKU
Asked but unknown
Null Flavor
Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

4.19 UICC/AJCC Perineurial Invasion 1.3.6.1.4.1.19376.1.3.11.25

Id1.3.6.1.4.1.19376.1.3.11.25Effective Date valid from 2015‑11‑04 16:20:42
StatusKyellow.png DraftVersion Label
NameUICC-perineural-invasionDisplay NameUICC Perineural Invasion
Description
   Observation for tumor spread coding the degree of perineural (lymphatic nerve sheet) invasion


2 Source Code Systems
2.16.840.1.113883.15.16 - TNM Edition8 UICC
2.16.840.1.113883.5.1008 - Null Flavor
Level/ TypeCodeDisplay NameCode SystemDescription
0‑L
Pn0
Pn0
TNM Edition8 UICCno perineural invasion
0‑L
Pn1
Pn1
TNM Edition8 UICCPerineural invasion
0‑L
PnX
PnX
TNM Edition8 UICCunknown

0‑L
ASKU
Asked but unknown
Null Flavor
Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

4.20 UICC/AJCC Mucosa 1.3.6.1.4.1.19376.1.3.11.26

Id1.3.6.1.4.1.19376.1.3.11.26Effective Date valid from 2015‑11‑04 16:22:04
StatusKyellow.png DraftVersion Label
NameUICC-mucosaDisplay NameUICC Mucosa
Source Code System
1.2.276.0.76.3.1.131.1.5.1
Level/ TypeCodeDisplay NameCode SystemDescription
0‑L
m1
m1
1.2.276.0.76.3.1.131.1.5.1restricted to mucosa, 1st third
0‑L
m2
m2
1.2.276.0.76.3.1.131.1.5.1restricted to mucosa, 2nd third
0‑L
m3
m3
1.2.276.0.76.3.1.131.1.5.1restricted to mucosa, 3rd third

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

4.21 UICC/AJCC Submucosa 1.3.6.1.4.1.19376.1.3.11.27

Id1.3.6.1.4.1.19376.1.3.11.27Effective Date valid from 2015‑11‑04 16:23:24
StatusKyellow.png DraftVersion Label
NameUICC-submucosaDisplay NameUICC Submucosa
Source Code System
1.2.276.0.76.3.1.131.1.5.1
Level/ TypeCodeDisplay NameCode SystemDescription
0‑L
sm1
sm1
1.2.276.0.76.3.1.131.1.5.1restricted to submucosa, 1st third
0‑L
sm2
sm2
1.2.276.0.76.3.1.131.1.5.1restricted to submucosa, 2nd third
0‑L
sm3
sm3
1.2.276.0.76.3.1.131.1.5.1restricted to submucosa, 3rd third

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

4.22 UICC/AJCC Localization of distant metastases 1.3.6.1.4.1.19376.1.3.11.28

Id1.3.6.1.4.1.19376.1.3.11.28Effective Date valid from 2015‑11‑04 16:26:53
StatusKyellow.png DraftVersion Label
NameUICC-distant-metastasis-localizationDisplay NameUICC Localization of distant metastases
DescriptionQualifier for M category coding the localization of distant metastasis in case of M1 or M2
Source Code System
2.16.840.1.113883.15.16 - TNM Edition8 UICC
Level/ TypeCodeDisplay NameCode System
0‑L
PUL
PUL
TNM Edition8 UICC
0‑L
OSS
OSS
TNM Edition8 UICC
0‑L
HEP
HEP
TNM Edition8 UICC
0‑L
BRA
BRA
TNM Edition8 UICC
0‑L
LYM
LYM
TNM Edition8 UICC
0‑L
OTH
OTH
TNM Edition8 UICC
0‑L
MAR
MAR
TNM Edition8 UICC
0‑L
PLE
PLE
TNM Edition8 UICC
0‑L
PER
PER
TNM Edition8 UICC
0‑L
ADR
ADR
TNM Edition8 UICC
0‑L
SKI
SKI
TNM Edition8 UICC

Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

4.23 UICC/AJCC Grade 3 tiered 1.3.6.1.4.1.19376.1.3.11.29

Id1.3.6.1.4.1.19376.1.3.11.29Effective Date valid from 2015‑11‑13 19:36:21
StatusKyellow.png DraftVersion Label
NameUICCgradeDisplay NameUICC Grade 3 tiered
DescriptionCoding of the grade of differentiation (malignancy) of tumors, coded by a four-, three-, or two-tiered grading system, often using the score of a special grading system for certain tumor types
2 Source Code Systems
2.16.840.1.113883.15.16 - TNM Edition8 UICC
2.16.840.1.113883.5.1008 - Null Flavor
Level/ TypeCodeDisplay NameCode SystemDescription
0‑L
1
G1
TNM Edition8 UICCgrade 1, well (highly) differentiated
0‑L
2
G2
TNM Edition8 UICCgrade 2, moderately differentiated
0‑L
3
G3
TNM Edition8 UICCgrade 3, poorly differentiated
0‑L
X
GX
TNM Edition8 UICCcannot be assessed

0‑L
ASKU
Asked but unknown
Null Flavor
Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

4.24 UICC/AJCC Grade 2 tiered 1.3.6.1.4.1.19376.1.3.11.30

Id1.3.6.1.4.1.19376.1.3.11.30Effective Date valid from 2015‑11‑13 19:43:09
StatusKyellow.png DraftVersion Label
NameUICCgrade-2Display NameUICC Grade 2 tiered
DescriptionCoding of the grade of differentiation (malignancy) of tumors, coded by a two-tiered grading system, sometimes using the score of a special grading system for certain tumor types
2 Source Code Systems
2.16.840.1.113883.15.16 - TNM Edition8 UICC
2.16.840.1.113883.5.1008 - Null Flavor
Level/ TypeCodeDisplay NameCode SystemDescription
0‑L
L
lG
TNM Edition8 UICClow grade, combining grade 1 and 2 (except urothelial tumors: only grade 1)
0‑L
H
hG
TNM Edition8 UICClow grade, combining grade 3 and 4 (except urothelial tumors: grade 2 through 4)
0‑L
X
X
TNM Edition8 UICCcannot be assessed

0‑L
ASKU
Asked but unknown
Null Flavor
Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

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4.25 UICC/AJCC Grade 4 tiered 1.3.6.1.4.1.19376.1.3.11.31

Id1.3.6.1.4.1.19376.1.3.11.31Effective Date valid from 2015‑11‑13 19:46:53
StatusKyellow.png DraftVersion Label
NameUICCgrade-4Display NameUICC Grade 4 tiered
DescriptionCoding of the grade of differentiation (malignancy) of tumors, coded by a four-tiered grading system, sometimes using the score of a special grading system for certain tumor types.
3 Source Code Systems
2.16.840.1.113883.15.16 - TNM Edition8 UICC
1.2.276.0.76.5.336
2.16.840.1.113883.5.1008 - Null Flavor
Level/ TypeCodeDisplay NameCode SystemDescription
0‑L
1
G1
TNM Edition8 UICCwell (highly) differentiated
0‑L
2
G2
TNM Edition8 UICCmoderately differentiated
0‑L
3
G3
TNM Edition8 UICCpoorly differentiated
0‑L
4
G4
TNM Edition8 UICCundifferentiated resp. anaplastic
0‑L
X
GX
TNM Edition8 UICCcannot be assessed
0‑L
0
0
1.2.276.0.76.5.336Malignes Melanom der Konjunktiva
0‑L
X
X
1.2.276.0.76.5.336nicht bestimmbar
0‑L
L
lG
1.2.276.0.76.5.336Low grade (G1 oder G2)
0‑L
M
mG
1.2.276.0.76.5.336intermediate (G2 oder G3)
0‑L
H
hG
1.2.276.0.76.5.336high grade (G3 oder G4)
0‑L
B
B
1.2.276.0.76.5.336Borderline-Malignität
0‑L
U
U
1.2.276.0.76.5.336unbekannt
0‑L
T
T
1.2.276.0.76.5.336trifft nicht zu

0‑L
ASKU
Asked but unknown
Null Flavor
Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

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4.26 UICC/AJCC Tumor Serum Markers 1.3.6.1.4.1.19376.1.3.11.32

Id1.3.6.1.4.1.19376.1.3.11.32Effective Date valid from 2015‑11‑08 18:26:39
StatusKyellow.png DraftVersion Label
NameUICCSerumTumorMarkersDisplay NameUICC Serum Tumor Markers
DescriptionObservation of serum levels of tumor markers coded for germ cell tumors
2 Source Code Systems
2.16.840.1.113883.15.16 - TNM Edition8 UICC
2.16.840.1.113883.5.1008 - Null Flavor
Level/ TypeCodeDisplay NameCode SystemDescription
0‑L
S0
S0
TNM Edition8 UICCserum tumor markers within normal limits
0‑L
S1
S1
TNM Edition8 UICCLDH < 1,5* normal limit AND ßHCG< 5000mIU/ml AND AFP <1000 ng/ml
0‑L
S2
S2
TNM Edition8 UICCLDH 1,5 - 10* normal limit OR ßHCG 5000 - 50000 mIU/ml OR AFP 1000 - 10000 ng/ml
0‑L
S3
S3
TNM Edition8 UICCLDH >10* normal limit OR ßHCG > 50000 mIU/ml OR AFP > 10000 ng/ml
0‑L
SX
SX
TNM Edition8 UICCNo information about serum tumor markers

0‑L
ASKU
Asked but unknown
Null Flavor
Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

4.27 ICD-O-3 Morphology 1.3.6.1.4.1.19376.1.3.11.33

Id1.3.6.1.4.1.19376.1.3.11.33Effective Date valid from 2015‑11‑13 14:08:46
StatusKyellow.png DraftVersion Label1st rev. (2013)
Nameicd-o-3-mDisplay NameICD-O-3 Morphology
DescriptionInternational classification of diseases / oncology, morphological part for typing of benign and malignant tumors. The morphology axis provides six-digit codes ranging from 8000/0 to 9989/3. The first four digits indicate the specific histological term, i.e. morphology (8000 through 9992).&#160;<span style="text-align: justify;">In developing the previous editions and the present edition of ICD-O, a particular effort was made to use the nomenclature appearing in the World Health Organization&#160;</span>

<span style="text-align: justify;">International Histological Classification of Tumours</span>&#160;<span style="text-align: justify;">series (WHO “Blue Books”)</span> <span style="text-align: justify;">7</span>

<span style="text-align: justify;">. This series covers all the principal sites of cancer and includes the morphology codes of ICD-O for each neoplasm.&#160;</span>All new histological classifications or modifications have been made by the WHO / IARC in so-called "Blue Books" by &#160;2011 are listed on-line: http://codes.iarc.fr/changes.php.<br clear="none"/>The fifth digit after a slash (/) is the behavior code, which indicates whether a tumor is malignant, benign, in situ, or uncertain (whether benign or malignant). <br clear="none"/>A separate, 6th, one-digit code may also be given for histologic 4-tiered grading (differentiation) or for the cell type in lymphatic neoplasia. &#160;<br clear="none"/>The fifth and the sixth digit are coded separately in value sets 1.3.6.1.4.1.19376.1.3.11.34 and 1.3.6.1.4.1.19376.1.3.11.35
A valid code from the code system:
Code System NameCode System IdCode System Version
 International Classification of Diseases for Oncology, version 3.2.16.840.1.113883.6.43.1
Or one of the following:
2 Source Code Systems
2.16.840.1.113883.6.43.1 - International Classification of Diseases for Oncology, version 3.
2.16.840.1.113883.5.1008 - Null Flavor
Level/ TypeCodeCode System

0‑L
ASKU
Asked but unknown
Null Flavor
Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

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4.28 ICD-O-3 Behavior 1.3.6.1.4.1.19376.1.3.11.34

Id1.3.6.1.4.1.19376.1.3.11.34Effective Date valid from 2015‑11‑13 18:54:30
StatusKyellow.png DraftVersion Label1st rev. (2013)
Nameicd-o-3-behaviorDisplay NameICD-O-3 Behavior
DescriptionCoding of the behavior of a tumor, coded by the first digit after slash in ICD-O-Morphology code
2 Source Code Systems
2.16.840.1.113883.6.43.1 - International Classification of Diseases for Oncology, version 3.
2.16.840.1.113883.5.1008 - Null Flavor
Level/ TypeCodeDisplay NameCode SystemDescription
0‑L
0
/0
International Classification of Diseases for Oncology, version 3.benign
0‑L
1
/1
International Classification of Diseases for Oncology, version 3.borderline malignancy or uncertain malignant potential
0‑L
2
/2
International Classification of Diseases for Oncology, version 3.noninvasiv resp. carcinoma in situ
0‑L
3
/3
International Classification of Diseases for Oncology, version 3.invasive resp. malignant primary tumor
0‑L
6
/6
International Classification of Diseases for Oncology, version 3.metastasis resp. secondary tumor, not used in German cancer registries
0‑L
9
/9
International Classification of Diseases for Oncology, version 3.malignant, uncertain whether primary or secondary tumor, not used in German cancer registries

0‑L
ASKU
asked but unknown
Null Flavor
Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

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4.29 ICD-O-3 Differentiation 1.3.6.1.4.1.19376.1.3.11.35

Id1.3.6.1.4.1.19376.1.3.11.35Effective Date valid from 2015‑11‑13 19:07:32
StatusKyellow.png DraftVersion Label1st rev. (2013)
Nameicd-o-3-differentiationDisplay NameICD-O-3 Differentiation
DescriptionCoding the cellular differentiation of malignant tumors, either the grade of malignancy (differentiation), or the cell line differentiation, coded by the second digit after the slash in ICD-O-3 Morphology axi
2 Source Code Systems
2.16.840.1.113883.6.43.1 - International Classification of Diseases for Oncology, version 3.
2.16.840.1.113883.5.1008 - Null Flavor
Level/ TypeCodeDisplay NameCode SystemDescription
0‑L
1
1
International Classification of Diseases for Oncology, version 3.well (highly) differentiated
0‑L
2
2
International Classification of Diseases for Oncology, version 3.moderately differentiated
0‑L
3
3
International Classification of Diseases for Oncology, version 3.poorly differentiated
0‑L
4
4
International Classification of Diseases for Oncology, version 3.undifferentiated resp. anaplastic
0‑L
5
5
International Classification of Diseases for Oncology, version 3.T-cell differentiation in lymphomas and leukemias
0‑L
6
6
International Classification of Diseases for Oncology, version 3.B-cell differentiation, pre-B-cells, B-precursor cells in lymphomas and leukemias
0‑L
7
7
International Classification of Diseases for Oncology, version 3.Null-cell, non-B-nonT-cell differentiation in lymphomas and leukemias
0‑L
8
8
International Classification of Diseases for Oncology, version 3.NK (natural killer)-cell differentiation in lymphomas and leukemias
0‑L
9
9
International Classification of Diseases for Oncology, version 3.grading not applied, not applicable, unknown; cell type not assessed or unknown

0‑L
ASKU
Asked but unknown
Null Flavor
Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

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4.30 ICD-O-3 Topography 1.3.6.1.4.1.19376.1.3.11.36

Id1.3.6.1.4.1.19376.1.3.11.36Effective Date valid from 2015‑11‑13 19:16:23
StatusKyellow.png DraftVersion Label1st rev. (2013)
Nameicd-o-3-topographyDisplay NameICD-O-3 Topography
DescriptionInternational classification of diseases / oncology, topographical part for typing of benign and malignant tumors. The topography axis (C-axis) uses the ICD-10 classification of malignant neoplasms (except those categories which relate to secondary neoplasms and to specified morphological types of tumours) for all types of tumours, thereby providing greater site detail for non-malignant tumours than is provided in ICD-10. In contrast to ICD-10, the ICD-O includes topography for sites of haematopoietic and reticuloendothelial tumors.
A valid code from the code system:
Code System NameCode System IdCode System Version
 International Classification of Diseases for Oncology, version 3.2.16.840.1.113883.6.43.1
Or one of the following:
2 Source Code Systems
2.16.840.1.113883.6.43.1 - International Classification of Diseases for Oncology, version 3.
2.16.840.1.113883.5.1008 - Null Flavor
Level/ TypeCodeCode System

0‑L
ASKU
asked but unknown
Null Flavor
Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.

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