cdapath:Vol3ContentModules

1 Introduction

The content of this entire section is identical to the actual 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 Additional Specified Observation section content module
• Reconfiguration of the entry content modules "Problem organizer", "Specimen procedure steps", and "Update information organizer"
• Introduction of child element content modules "X-specimen identified", "UICC/AJCC-TNM observation", "ICD-O-3 observation", "Assessment scales observation", "Pertinent insurance information".
• 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 trial implementation.

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	Trial Implementation

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.

• Note 4: A new version of a report SHOULD have an Update Organizer <entry> in its Diagnostic Conclusion <section> carrying information about what has been changed in comparison with the immediate previous report, and what is the clinical significance of that change.

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:

Branch 1.3.6.1.4.1.19376.1.3.4 is used to identify instances in the examples of AP content built by XD-LAB in the PaLM domain.

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 and 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/Snomed International
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 International
2.16.840.1.113883.5.6	ActClass Codesystem for Act Classes	HL7 International
2.16.840.1.113883.5.1052	Act Site Codesystem for Act Sites	HL7 International
2.16.840.1.113883.5.1065	ProcedureMethod Codesystem for Procedure Methods	HL7 International
2.16.840.1.113883.5.111	Role Code Codesystem for Role Codes	HL7 International
2.16.840.1.113883.5.129	SpecimenType Codesystem for Specimen Types	HL7
2.16.840.1.113883.5.83	ObservationInterpretation One or more codes specifying a rough qualitative interpretation of the observation, such as "normal", "abnormal", "below normal", "change up", "resistant", "susceptible", etc.	HL7 International
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 International
2.16.840.1.113883.6.3	ICD-10 International Classification of Diseases revision 10	WHO
2.16.840.1.113883.6.43.1	ICD-O-3 International Classification of Diseases for Oncology, 3rd edition, revision 1, 2013	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	DICOM
2.16.840.1.113883.15.16	TNM 8th edition Internationally agreed-upon standards to describe and categorize cancer stages and progression	Union for International Cancer Control (UICC) & American Joint Committee on Cancer (AJCC)
2.16.840.1.113883.15.6	TNM 7th edition Internationally agreed-upon standards to describe and categorize cancer stages and progression	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	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	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
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	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 Germany
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 Germany

5.3 Value Sets

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

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 PaLM TF-3. This extension has been created by former 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	Comment	IHE PCC TF-2:6.3.4.6
1.3.6.1.4.1.19376.1.3.3.1.1	CDA R2	Human Patient	IHE PaLM TF-3:6.3.2.11.1
1.3.6.1.4.1.19376.1.3.1.3	CDA R2	Specimen Received	IHE PaLM TF-3:6.3.4.6
1.3.6.1.4.1.19376.1.3.1.6	CDA R2	Laboratory Observation	IHE PaLM TF-3:6.3.4.13
1.3.6.1.4.1.19376.1.3.3.1.4	CDA R2	Intended Recipient	IHE PaLM TF-3:6.3.2.14
1.3.6.1.4.1.19376.1.3.3.1.6	CDA R2	Ordering Provider (ordering physician)	IHE PaLM TF-3:6.3.2.17
1.3.6.1.4.1.19376.1.3.3.1.7	CDA R2	Laboratory Performer	IHE PaLM TF-3:6.3.2.20

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

• HL7 CDA conventions are defined in the IHE Technical Frameworks General Introduction Appendix E

• 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 1.3.6.1.4.1.19376.1.3.3

Section unchanged, as in PaLM TF-3

6.3.1.2 Anatomic Pathology Structured Report Content Module 1.3.6.1.4.1.19376.1.8.1.1.1

This Content Integration Profile describes a surgical pathology report as an electronic document to be published towards a document sharing resource such as an Electronic Health Record (EHR) or Personal Health Record (PHR) shared by a community of care providers, using one of the document sharing profiles defined in ITI-TF.
Such an electronic document contains the set of releasable results produced by an surgical pathology laboratory in fulfillment of an Order or an Order Group for a patient. The report is shared in a human-readable format. In addition, this electronic anatomic pathology report SHALL contain diagnostic conclusions in a machine-readable format, to facilitate the integration of these observations in the database of a consumer system.
This Document Content Module defines the base set of constraints that apply to all AP structured reports, related to any kind of lesion or diagnostic problem (cancers, benign neoplasms as well as non-neoplastic conditions) as well as for Cytopathology.
In other words, this is the generic template for any AP structured report.

This document content module is identified by templateId 1.3.6.1.4.1.19376.1.8.1.1.1.
The body of this Document Content Module specifies a common hierarchy of sections and entries depicted by figure 10.4.1-1 in Volume 1. The only mandatory section is the Diagnostic Conclusion Section. And the only mandatory entry is the Problem Organizer Entry below this section.

The specification of this Document Content Module is built and published on Art-Decor Pathology Structured Reporting, including schematron rules, code systems and value sets.

Id	1.3.6.1.4.1.19376.1.8.1.1.1	Effective Date	valid from 2014‑05‑13 11:57:57
Status	Draft	Version Label	2.0
Name	AnatomicPathologyStructuredReportContentModule	Display Name	Anatomic Pathology Structured Report Content Module
Description Anatomic Pathology Structured Report Content Module.  This document content module represents the generic set of constraints applied to any structured report for surgical pathology in all fields of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as for Cytopathology.  The body of this Document Content Module specifies a common hierarchy of sections and entries depicted by figure 10.4.1-1 in Volume 1 IHE_PaLM_Suppl_APSR 2.0. The only mandatory section is the Diagnostic Conclusion Section. And the only mandatory entry is the Problem Organizer Entry below this section.
Context	Pathname /
Label	PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module
Classification	CDA Document Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 0 templates, Uses 20 templates Uses as Name Version 1.3.6.1.4.1.19376.1.3.3.1.1 Include Human Patient (2017) 2017‑06‑07 1.3.6.1.4.1.19376.1.8.1.4.2 Include CDA author IHE 2016‑06‑21 14:02:11 2.16.840.1.113883.10.12.103 Include CDA dataEnterer 2005‑09‑07 1.3.6.1.4.1.19376.1.8.1.4.6 Containment CDA Informant(Header&Body) APSR2 (2.0) 2016‑07‑08 11:22:58 2.16.840.1.113883.10.12.104 Include CDA custodian 2005‑09‑07 1.3.6.1.4.1.19376.1.3.3.1.4 Include XD-LAB Information Recipient (2017) 2008‑08‑08 1.3.6.1.4.1.19376.1.3.10.2.4 Include XD-LAB LegalAuthenticator (2017) 2016‑07‑05 1.3.6.1.4.1.19376.1.8.1.4.3 Include CDA authenticator IHE 2016‑07‑09 15:03:59 1.3.6.1.4.1.19376.1.3.3.1.6 Include Ordering Provider (2017) 2008‑08‑08 1.3.6.1.4.1.19376.1.8.1.4.1 Include CDA Participant Specimen Collector 2016‑06‑13 14:21:13 1.3.6.1.4.1.19376.1.3.10.2.5 Include CDA Participant Pertinent Insurance Information 2017‑11‑13 16:52:30 1.3.6.1.4.1.19376.1.3.3.1.7 Containment Laboratory Performer (2017) 2008‑08‑08 2.16.840.1.113883.10.12.113 Include CDA componentOf 2005‑09‑07 1.3.6.1.4.1.19376.1.8.1.2.1 Containment Clinical Information Section (2.0) 2014‑05‑13 14:38:08 1.3.6.1.4.1.19376.1.8.1.2.2 Containment Intraoperative Observation Section (2.0) 2014‑05‑13 19:29:16 1.3.6.1.4.1.19376.1.8.1.2.3 Containment Macroscopic Observation Section (2.0) 2014‑05‑13 11:57:09 1.3.6.1.4.1.19376.1.8.1.2.4 Containment Microscopic Observation Section (2.0) 2014‑05‑13 14:25:17 1.3.6.1.4.1.19376.1.3.10.3.1 Containment Additional Specified Observation Section (2.0) 2016‑11‑13 14:28:08 1.3.6.1.4.1.19376.1.8.1.2.5 Containment Diagnostic Conclusion Section (2.0) 2014‑05‑13 19:31:26 1.3.6.1.4.1.19376.1.8.1.2.6 Containment Procedure Steps Section (2.0) 2014‑05‑13 19:33:12
Relationship	Specialization: template 2.16.840.1.113883.10.12.1 (2005‑09‑07)
Example	example for use case #1 <ClinicalDocument xsi:schemaLocation="urn:hl7-org:v3 infrastructure/cda/CDA_extended.xsd">   <realmCode code="UV"/>  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>  <templateId root="1.3.6.1.4.1.19376.1.8.1.1.1"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_1" assigningAuthorityName="IHE PaLM Technical Committee"/>  <code code="60568-3" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology Synoptic report"/>  <title>Anatomic Pathology Structured Report - Breast Biopsy</title>  <effectiveTime value="201001041605-0500"/>  <confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25"/>  <languageCode code="en-US"/>  <setId root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008" assigningAuthorityName="IHE PaLM Technical Committee"/>  <versionNumber value="1"/>  <!-- Patient -->   <recordTarget>     <patientRole>       <id extension="0411886319605719371016" root="1.3.6.1.4.1.19376.1.8.9.2"/>      <addr use="HP">         <streetAddressLine>39 East Street</streetAddressLine>        <postalCode>69499</postalCode>        <city>Appleton</city>        <state>WI</state>        <country>United States</country>      </addr>      <telecom nullFlavor="NASK"/>      <patient>         <name>           <prefix>Miss</prefix>          <given>EVE</given>          <family qualifier="BR">ONEWOMAN</family>        </name>        <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>        <birthTime value="19710921"/>      </patient>    </patientRole>  </recordTarget>  <!-- one or more author(s) of the report, with authoring time -->   <author>     <templateId root="1.3.6.1.4.1.19376.1.8.1.4.2"/>    <time value="20100104131933-0500"/>    <assignedAuthor>       <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>      <addr nullFlavor="MSK"/>      <telecom value="tel:+33-602030499"/>      <assignedPerson>         <name>           <given>Marcel</given>          <family>Pathologist</family>          <suffix>Ph D</suffix>        </name>      </assignedPerson>      <representedOrganization>         <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>        <name>CANCER INSTITUTE</name>        <telecom nullFlavor="MSK"/>        <addr nullFlavor="MSK"/>      </representedOrganization>    </assignedAuthor>  </author>  <!-- one or more transcriptionists, with transcription time -->   <dataEnterer>     <time value="20100104131720-0500"/>    <assignedEntity>       <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="A32"/>      <addr nullFlavor="MSK"/>      <telecom nullFlavor="MSK"/>      <assignedPerson>         <name>           <given>Adeline</given>          <family>Medsecret</family>        </name>      </assignedPerson>    </assignedEntity>  </dataEnterer>  <informant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Body) APSR2' (dynamic), not used in use case #1 -->   </informant>  <!-- The unique custodian of this document is the sending pathology lab that will administer it (further updates, deprecation) -->   <custodian>     <assignedCustodian>       <representedCustodianOrganization>         <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>        <name>CANCER INSTITUTE</name>        <telecom use="PUB" value="0466666666"/>        <addr>           <streetAddressLine>38 Cramberry Street</streetAddressLine>          <postalCode>69499</postalCode>          <city>Appleton</city>          <state>WI</state>        </addr>      </representedCustodianOrganization>    </assignedCustodian>  </custodian>  <!-- One or more additional intended recipients (other than the ordering physician) -->   <informationRecipient>     <templateId root="1.3.6.1.4.1.19376.1.3.3.1.4"/>    <intendedRecipient>       <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="987"/>      <addr>         <streetAddressLine>1600 Clifton Road</streetAddressLine>        <city>Atlanta</city>        <state>GA</state>        <postalCode>30333</postalCode>      </addr>      <telecom value="tel:404-639-3535"/>      <informationRecipient>         <name>           <family>WOULDLIKETOKNOW</family>          <given>Thomas</given>        </name>      </informationRecipient>    </intendedRecipient>  </informationRecipient>  <!-- The unique legal authenticator: The person assuming the final responsibility of the report and signing it -->   <legalAuthenticator>     <time value="20100104152503-0500"/>    <signatureCode code="S"/>    <assignedEntity>       <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>      <assignedPerson>         <name>           <given>Marcel</given>          <family>Pathologist</family>        </name>      </assignedPerson>    </assignedEntity>  </legalAuthenticator>  <!-- Zero or more additional content validator(s): pathologists having validated some part of the report -->   <authenticator>     <templateId root="1.3.6.1.4.1.19376.1.8.1.4.3"/>    <time value="20100104142503-0500"/>    <signatureCode code="S"/>    <assignedEntity>       <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567898"/>      <addr nullFlavor="MSK"/>      <telecom nullFlavor="MSK"/>      <assignedPerson>         <name>           <given>Jonas</given>          <family>Jones</family>          <prefix>MD</prefix>        </name>      </assignedPerson>    </assignedEntity>  </authenticator>  <!-- The ordering physician -->   <participant typeCode="REF">     <templateId root="1.3.6.1.4.1.19376.1.3.3.1.6"/>    <time>       <high value="20091231"/>    </time>    <associatedEntity classCode="PROV">       <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567892"/>      <addr nullFlavor="NASK"/>      <telecom value="tel:0147150000" use="EC"/>      <associatedPerson>         <name>           <prefix>Doctor</prefix>          <given>Eva</given>          <family>Surgeon</family>          <suffix>Ph D</suffix>        </name>      </associatedPerson>    </associatedEntity>  </participant>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.1 'CDA participant specimen collector' (dynamic) 0..* R, not used in use case #1 -->   <!-- include template 1.3.6.1.4.1.19376.1.3.10.2.5 'CDA participant pertinent insurance information' (dynamic) 0..1 R, not used in use case #1 -->   <!-- Identification of the order, extension is Order-ID -->   <inFulfillmentOf>     <order>       <id root="1.3.6.1.4.1.19376.1.8.9.8" extension="12345"/>    </order>  </inFulfillmentOf>  <!-- Documented act(s): The pathology examination procedure, extension is Accession number -->   <documentationOf>     <serviceEvent>       <id root="1.3.6.1.4.1.19376.1.8.9.9" extension="A7102400008"/>      <code code="371528001" displayName="Pathology report (record artifact)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>      <lab:statusCode code="completed"/>      <effectiveTime>         <!-- Start: Date&time of reception of this order and the attached specimens -->         <low value="200912300922-0500"/>        <!-- End -->         <high value="201001041605-0500"/>      </effectiveTime>      <!-- Performing laboratory -->       <performer typeCode="PRF">         <templateId root="1.3.6.1.4.1.19376.1.3.3.1.7"/>        <time>           <high value="201001041605-0500"/>        </time>        <assignedEntity>           <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>          <representedOrganization>             <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>            <name>CANCER INSTITUTE</name>            <telecom nullFlavor="MSK"/>            <addr nullFlavor="MSK"/>          </representedOrganization>        </assignedEntity>      </performer>    </serviceEvent>  </documentationOf>  <!-- include template 1.3.6.1.4.1.19376.1.3.1.9999.10.9.16 'RelatedDocument Parent Document' (dynamic) 0..1 R, not used in use case #1 -->   <!-- Patient encounter: The patient stay in the hospital where the surgery was performed -->   <componentOf>     <encompassingEncounter>       <id root="1.3.6.1.4.1.19376.1.8.9.7" extension="234567890"/>      <code code="ACUTE" displayName="inpatient acute"/>      <effectiveTime>         <high value="2201001040735-0500"/>      </effectiveTime>      <location typeCode="LOC">         <healthCareFacility classCode="SDLOC">           <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="11223344"/>          <serviceProviderOrganization classCode="ORG" determinerCode="INSTANCE">             <name>Surgery theater</name>            <asOrganizationPartOf>               <wholeOrganization>                 <name>CANCER INSTITUTE</name>              </wholeOrganization>            </asOrganizationPartOf>          </serviceProviderOrganization>        </healthCareFacility>      </location>    </encompassingEncounter>  </componentOf>  <!-- Structured body -->   <component typeCode="COMP" contextConductionInd="true">     <structuredBody classCode="DOCBODY" moodCode="EVN">       <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.1 'Clinical Information Section' (2014-05-13T14:38:08) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.2 'Intraoperative Observation Section' (2014-05-13T19:29:16) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.3 'Macroscopic Observation Section' (2014-05-13T11:57:09) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.4 'Microscopic Observation Section' (2014-05-13T14:25:17) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.3.10.3.1 'Additionally Specified Observation Section' (2016-11-13T14:28:08) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.5 'Diagnostic Conclusion Section' (2014-05-13T19:31:26) -->       </component>      <component typeCode="COMP" contextConductionInd="true">         <!-- template 1.3.6.1.4.1.19376.1.8.1.2.6 'Procedure Steps Section' (2014-05-13T19:33:12) -->       </component>    </structuredBody>  </component></ClinicalDocument>
Item DT Card Conf Description Label hl7:ClinicalDocument 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode cs 1 … 1 F DOCCLIN @moodCode cs 1 … 1 F EVN hl7:templateId II 1 … 1 M This element is identifying the set of constraints applied to the CDA R2 standard by this IHE specification of a AP report. The following templateId SHALL be present and valued as follows to indicate compliance with the APSR 2.0 content module specification. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.1.1 hl7:realmCode CS (extensible) 1 … 1 M This element SHALL be present and is valued from the RealmOfUse [2.16.840.1.113883.1.11.11050] subset, within the VocabularyDomainQualifier value set. In the international context of this profile used as it is without any further extension, the realm code SHALL be <realmCode code="UV"/> (universal). Whenever a national extension has been defined and is used, the realm code SHALL identify this national extension. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:typeId II 1 … 1 M This element is a technology-neutral explicit reference to the standard CDA R2. It SHALL be present and valued as follows: ClinicalDocument/typeId@root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models); ClinicalDocument.typeId@extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description). PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @root uid 1 … 1 F 2.16.840.1.113883.1.3 @extension st 1 … 1 F POCD_HD000040 hl7:id II 1 … 1 M ClinicalDocument/Id SHALL be present. It represents the unique instance identifier of the clinical document. The combination of the root and extension attributes SHALL provide a globally unique identifier, in accordance with CDA R2, without further constraints. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @root uid 1 … 1 R Here the OID for PAT exemplary instances, in practice the OID of the LIS @extension st 1 … 1 R Here a hypothetical document ID, most often derived from the accession number   Constraint A report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report. The unique id of the current revision of the report is carried by the id element, and is composed of  id@root, which SHALL be an OID, and optionally id@extension, which can be any string so that the concatenation of the two attributes root and extension provide a globally unique id, which identifies this release of the report.    Example Report ID from use case #1 <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_1" assigningAuthorityName="IHE PaLM Technical Committee"/> hl7:code CE (required) 1 … 1 M ClinicalDocument/code SHALL be present. The document type of this content module is always <code code="60568-3" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology Synoptic report" codeSystemName="LOINC"/> PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @code CONF 1 … 1 F 60568-3 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) @codeSystemName 1 … 1 F LOINC @displayName 1 … 1 F Pathology Synoptic report hl7:title ST 1 … 1 M The APSR <title> SHALL be present. It is the local translation of the code@displayName. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF element content shall be "Anatomic Pathology Structured Report"   Example Report title from use case #1 <title>ANATOMIC PATHOLOGY REPORT - BREAST BIOPSY</title> hl7:effectiveTime TS 1 … 1 M ClinicalDocument/effectiveTime SHALL be present. It contains the creation date & time of the laboratory report as an electronic document. In case this is a new revision replacing a previous version (identified in parentDocument), this is the date & time of the new revision. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:confidentialityCode CE (required) 1 … 1 M ClinicalDocument/confidentialityCode SHALL be present in accordance with the HL7 CDA R2 standard. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (2014‑06‑09) hl7:language​Code CS (required) 1 … 1 M ClinicalDocument/languageCode SHALL be present in accordance with the HL7 CDA R2 standard. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (2014‑03‑26) hl7:setId II 1 … 1 M ClinicalDocument/setId SHALL be present to enable further updates of the clinical document. It is an identifier that is common across all revisions of this AP report. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @root uid 1 … 1 R @extension st 1 … 1 R   Constraint A report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report. The setId element provides a globally unique identifier that is common across all successive revisions of the report. This identifier is similarly composed of setId@root, which SHALL be an OID, and optionally setId@extension.    Example Report set ID from use case #1 <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008" assigningAuthorityName="IHE PaLM Technical Committee"/> hl7:versionNumber INT 0 … 1 R ClinicalDocument/versionNumber MAY be present. As requested by the CDA standard, it is an integer value used as versioning. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @value int 1 … 1 R   Constraint A report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report. The version number of the current revision of the report is a positive integer (1, 2 …) provided in the versionNumber element.   Example Report version number for use case #1 <versionNumber value="1"/> Included 1 … 1 M from 1.3.6.1.4.1.19376.1.3.3.1.1 Human Patient (2017‑06‑07) The Patient. The anatomic pathology report is related to ONE SINGLE patient.  A patient SHALL be identified with at least one unique patientRole/Id.   The patient address and telecom SHALL be provided (or null flavored).   The patient identity SHALL provide AT LEASTthe patient full name, sex and date/time of birth.  hl7:recordTarget 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:patientRole 1 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:id II 1 … * R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:addr AD 1 … * All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:telecom TEL 1 … * All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:patient 1 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:id II 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:name PN 1 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:administrative​Gender​Code CE 1 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:birthTime TS 1 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module Included 1 … * M from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11) The Author Content Module represents an author of the report. This element is repeatable. The sub-element  author/time  carries the date/time of the authoring action.  At least one ClinicalDocument/author SHALL be present with a time in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. The author/time element carries the date&time the AP report was produced. The AP report can be authored by a software system or by a person or by both. Source: PaLM Suppl.APSR 2.0‑3: 6.3.6.2 hl7:author 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @typeCode cs 1 … 1 F AUT   Example author is a person <author typeCode="AUT" contextControlCode="OP">   <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">     <!-- ... -->   </assignedAuthor></author> hl7:templateId 1 … 1 M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.4.2 hl7:time TS 1 … 1 M The 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 hl7:assignedAuthor 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F ASSIGNED hl7:id II 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Choice 1 … 1 The author is either an assigned person or an authoring device. Elements to choose from: hl7:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Included 0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07) The name(s) SHALL be given. @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:softwareName SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:represented​Organization 0 … 1 PaLM 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> Included 0 … 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. @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:asOrganizationPartOf 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F PART hl7:id II 0 … * R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.111 (Role Code) hl7:statusCode CS 0 … 1 PaLM 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) hl7:effectiveTime IVL_TS 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:wholeOrganization 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Included 0 … * R from 2.16.840.1.113883.10.12.103 CDA dataEnterer (2005‑09‑07) Transcriptionist hl7:dataEnterer 0 … * R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode 0 … 1 F ENT @context​Control​Code 0 … 1 F OP hl7:time TS 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:assignedEntity 1 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:informant 0 … * R Zero or more informant MAY be mentioned in the header of the report. 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. These two elements are defined in the content module “Informant”. 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. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.4.6']] Included 1 … 1 M from 2.16.840.1.113883.10.12.104 CDA custodian (2005‑09‑07) ClinicalDocument/custodian SHALL be present with an id in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. It represents the organization that is in charge of maintaining the AP report. hl7:custodian 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode 0 … 1 F CST hl7:assignedCustodian 1 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode 0 … 1 F ASSIGNED hl7:represented​Custodian​Organization 1 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 1 … * M PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:name ON 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:telecom TEL 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:addr AD 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module Included 0 … * R from 1.3.6.1.4.1.19376.1.3.3.1.4 XD-LAB Information Recipient (2008‑08‑08) The Intended Recipient Content Module represents a healthcare provider,   other than the ordering physician, expecting to receive a copy of the report. This repeatable element informationRecipient of the CDA header is used to list the intended recipients who were known at the time the report was created and issued.  Source: PaLM TF-3: 6.3.2.14 hl7:information​Recipient 0 … * R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:templateId II 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.3.1.4 hl7:intended​Recipient 1 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:id II 0 … * R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:addr AD 1 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:telecom TEL 1 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:information​Recipient 0 … 1 Contains 1.3.6.1.4.1.19376.1.3.10.9.18 PlayingEntity or person with Name (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:received​Organization 0 … 1 Contains 1.3.6.1.4.1.19376.1.3.10.9.13 Organization with Name, Addr, Telecom (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module Included 1 … 1 M from 1.3.6.1.4.1.19376.1.3.10.2.4 XD-LAB LegalAuthenticator (2016‑07‑05) The Legal authenticator Content Module describes a pathologist having verified the content of the report, using the element legalAuthenticator. The report SHALL have one legal Authenticator Source: PaLM TF-3: 6.3.2.15 hl7:legalAuthenticator 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:time TS 1 … 1 R The sub-element time carries the date&time this legal authentication took place. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:signatureCode CS 1 … 1 R The sub-element signatureCode carries the “signed” (S) status PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @code CONF 0 … 1 F S hl7:assignedEntity 1 … 1 R All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:addr AD 1 … * R Constrained by this specification to require the presence of name, addr and telecom. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:telecom TEL 1 … * R Constrained by this specification to require the presence of name, addr and telecom. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:assigned​Person 0 … 1 All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. Contains 1.3.6.1.4.1.19376.1.3.10.9.18 PlayingEntity or person with Name (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:represented​Organization 0 … 1 All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom. Contains 1.3.6.1.4.1.19376.1.3.10.9.13 Organization with Name, Addr, Telecom (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module Included 0 … * R from 1.3.6.1.4.1.19376.1.8.1.4.3 CDA authenticator IHE (2016‑07‑09 15:03:59) The Content validator Content Module 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. Source: PaLM Suppl. APSR 2.0-3: 6.3.6.3 hl7:authenticator 0 … * R PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator @typeCode cs 1 … 1 F AUTHEN hl7:templateId 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.4.3 hl7:time TS 1 … 1 R Time of validation PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator hl7:assignedEntity 0 … 1 C AssignedPerson SHALL be given with name, representedOrganization MAY be given. Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (2005‑09‑07) PaLM Suppl. APSR 2.0‑3: 6.3.6.3 Content validator Included 1 … 1 R from 1.3.6.1.4.1.19376.1.3.3.1.6 Ordering Provider (2008‑08‑08) The Ordering Provider Content Module represents the physician who has submitted the specimen examination order to the anatomic pathology laboratory. As specified in PaLM TF-3, this physician is represented in the CDA header as a participant element with the typeCode attribute valued “REF”. The sub-element participant/time carries the date/time of issuance of the order. Source: PaLM TF-3: 6.3.2.17 hl7:participant 1 … 1 R Referral Ordering Physician PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 F REF hl7:templateId II 1 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.3.1.6 hl7:time IVL_TS 1 … 1 R This element represents the date and time the order was placed. Time MAY be present. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:associated​Entity 1 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:addr AD 1 … * R The address of this person (referral ordering physician) SHALL be present. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:telecom TEL.AT 1 … * R The telecom of this person (referral ordering physician) SHALL be present. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   Schematron assert role  error     test not(hl7:assigned​Person) or hl7:assigned​Person/hl7:name     Message The <name> sub-element SHALL be present when <assignedPerson> present.   hl7:associated​Person 0 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:scoping​Organization 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module Included 0 … * R from 1.3.6.1.4.1.19376.1.8.1.4.1 CDA Participant Specimen Collector (2016‑06‑13 14:21:13) The 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. Source: PAT TF-3: 6.2.6.1 hl7:participant 0 … * R The 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 @typeCode cs 1 … 1 F DIST hl7:templateID II 1 … 1 M PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.4.1 hl7:time IVL_TS 1 … 1 M Specimen 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 hl7:associated​Entity 0 … 1 R At 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 @classCode cs 1 … 1 F PROV hl7:id II 1 … * R PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector hl7:addr AD 1 … * R PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector hl7:telecom TEL.AT 1 … * R PaLM Suppl. APSR 2.0‑3:6.3.6.1 Specimen collector hl7:associated​Person 0 … * C Person 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 hl7:scoping​Organization 0 … 1 C Organization 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 Included 0 … 1 R from 1.3.6.1.4.1.19376.1.3.10.2.5 CDA Participant Pertinent Insurance Information (2017‑11‑13 16:52:30) Key insurance information of the patient  hl7:participant 0 … 1 R Insurance information of the patient in context for reporting to cancer registries (in Germany) PaLM Suppl. 2.0‑3:6.3.6.13 @typeCode cs 1 … 1 F HLD hl7:templateId II 1 … * M PaLM Suppl. 2.0‑3:6.3.6.13 @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.10.2.5 hl7:time IVL_TS 0 … 1 R time shows the end of the current insurance period, e.g. end of the quartal PaLM Suppl. 2.0‑3:6.3.6.13   Example <time>   <high value="20171231"/></time> hl7:associated​Entity 1 … 1 M Data of the insured person PaLM Suppl. 2.0‑3:6.3.6.13 @classCode cs 1 … 1 F POLHOLD hl7:id II 0 … * R ID(s) of the insured person (patient), e.g. ID of the insured, ID of the health card, etc. PaLM Suppl. 2.0‑3:6.3.6.13 hl7:code CE 0 … 1 R status of the insured person PaLM Suppl. 2.0‑3:6.3.6.13 @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.111 (Role Code)   Example <code code="SELF" codeSystem="2.16.840.1.113883.5.111" displayName="self">   <translation code="1" codeSystem="2.16.840.1.113883.3.7.1.1" displayName="member"/></code> hl7:translation CV 0 … 1 R further codes of the status of the insured person, e.g. for Germany from value set S_KBV_VERSICHERTENSTATUS  1.2.276.0.76.11.162 PaLM Suppl. 2.0‑3:6.3.6.13 hl7:addr AD 0 … 1 R PaLM Suppl. 2.0‑3:6.3.6.13 hl7:telecom TEL 0 … * R PaLM Suppl. 2.0‑3:6.3.6.13 hl7:associated​Person 0 … 1 R Data of the insured person, which may be different from the patient.  Contains 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07) PaLM Suppl. 2.0‑3:6.3.6.13 hl7:scoping​Organization 1 … 1 R Data of the Insurance company, including the ID, the address data and the name. In Germany the ID is formed by the ID itself (@extension = so-called IKNR) and the OID for IKNR  (@root="1.2.276.0.76.4.5") in Germany. Contains 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07) PaLM Suppl. 2.0‑3:6.3.6.13 hl7:inFulfillmentOf 0 … 1 R The inFulfillmentOf/order element MAY be present. It represents the Placer Order or the Placer Group that was fulfilled, the Id of which is carried by inFulfillmentOf/order/id. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 F FLFS hl7:order 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode cs 1 … 1 F ACT @moodCode cs 1 … 1 F RQO hl7:id II 1 … * R Placer order group ID or Placer order ID PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:documentationOf 1 … 1 M Documented act. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 F DOC hl7:serviceEvent 1 … 1 M The AP report is documenting a service (documentationOf/serviceEvent) performed by a surgical pathology laboratory. The Laboratory Performer Content Module represents this laboratory, and is fully described in the sub-element  documentationOf/serviceEvent/performer. In case more than one laboratory contributed to a service, only the primary laboratory is in the CDA header, attached to the serviceEvent element, and the other (secondary) laboratories are described only in the sections of the report that they contributed to, in the body of the report. Source: PaLM TF3: 6.3.2.19 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode cs 1 … 1 R @moodCode cs 1 … 1 R hl7:id II 1 … * M ID of the Act, i.e. Accession number PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:code CE (extensible) 0 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF @code shall be "PATREPE" @codeSystem shall be "2.16.840.1.113883.5.4" @codeSystemName shall be "HL7 ActCode" @displayName shall be "pathology report entry task" or @code shall be "371528001" @codeSystem shall be "2.16.840.1.113883.6.96" @codeSystemName shall be "SCT" @displayName shall be "Pathology report (record artifact)" hl7:effectiveTime IVL_TS 0 … 1 R Use of sub element documentationOf/serviceEvent/effectiveTime to document the time boundaries of events in the document is appropriate. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module ihe-lab:statusCode CS (required) 0 … 1 R The statusCode below documentationOf/serviceEvent is an extension to the CDA R2 standard, added by PaLM TF-3 to distinguish a preliminary report (statusCode@code="active") from a final report (statusCode@code="completed").  The statusCode sub element is  further described in section A.3 of PaLM TF-3. This sub-element is required. When it is not there, the documented Act is assumed to be completed and the report is assumed to be a final report. This extension to the standard is protected by a dedicated namespace associated in the ClinicalDocument element to the prefix lab: <Clinical Document  xmlns:lab="urn:oid:1.3.6.1.4.1.19376.1.3.2" … >  Source: PaLM TF3: 6.3.2.19 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   Constraint The statusCode@code="completed" is only applicable, if ALL content modules of the Clinical Document have the statusCode@code="completed", too, or have the statusCode@code="aborted".   CONF The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.4 ActStatusActiveCompleted (2008‑08‑08)   Schematron assert role  error     test hl7:serviceEvent/lab:statusCode[@code='completed']     Message Status code of all Content Modules SHALL be "complete" or "aborted"   hl7:performer 0 … * R Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module where [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.3.1.7']] hl7:relatedDocument 0 … 1 R ClinicalDocument/relatedDocument/parentDocument This element SHALL be present in case of an update replacement of a previous report. In this case relatedDocument@typeCode attribute SHALL be valued "RPLC", the new report replacing the parent one. Note 1: A non-final AP structured 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. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 F RPLC   relatedDocument@typeCode attribute SHALL be valued "RPLC" hl7:parentDocument ANY 1 … 1 M PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:id II 1 … 1 M SHALL be equal to ClinicalDocument/ id of the replaced document. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:setId II 1 … 1 M SHALL have the same value in the new report as in the replaced report. PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:versionNumber INT 0 … 1 R SHALL have the same value as in the replaced report (when provided there). PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module Included 0 … 1 R from 2.16.840.1.113883.10.12.113 CDA componentOf (2005‑09‑07) The ClinicalDocument/componentOf/encompassingEncounter element MAY be present. It describes the encounter during which the reported AP observations were ordered. When present the encounter SHALL: be identified with an id element: encompassingEncounter/id The encounter SHALL have an effective time that represents the time interval (possibly still running, e.g., an inpatient current stay) of the encounter or a point in time at which the encounter took place (e.g., an outpatient consultation): encompassingEncounter/ effectiveTime The encounter MAY provide any number of encounter participants (encompassingEncounter/encounterParticipant/assignedEntity). When present, encounter participants SHALL be in accordance with the HL7 CDA R2 standard with a time and further constrained by this specification to require the presence of name, addr and telecom. Additionally, the encounter participant SHALL have a typeCode with one the values selected from the x_EncounterParticipant domain: The encounter MAY precise the patient location during this encounter. This is the healthcare facility in which the patient was located when the reported AP observations were ordered: encompassingEncounter/location/healthCareFacility. This healthcare facility can be represented as a physical place (e.g., room, floor, building, office) or as an organization (e.g., service, department, team) or both: healthCareFacility/location, healthCareFacility/serviceProviderOrganization. hl7:componentOf 0 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode 0 … 1 F COMP hl7:encompassing​Encounter 1 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode 0 … 1 F ENC @moodCode 0 … 1 F EVN hl7:id II 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:code CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC) hl7:effectiveTime IVL_TS 1 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:discharge​Disposition​Code CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF shall be drawn from concept domain "EncounterDischargeDisposition" hl7:responsible​Party 0 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode 0 … 1 F RESP hl7:encounterParticipant 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 R   CONF The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC) hl7:time IVL_TS 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:assignedEntity 1 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:location 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode 0 … 1 F LOC hl7:health​Care​Facility 1 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode 0 … 1 F SDLOC hl7:id II 0 … * PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:code CE 0 … 1 PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC) hl7:location 0 … 1 Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:service​Provider​Organization 0 … 1 Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module hl7:component 1 … 1 R Body of the CDA Clinical document PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:structuredBody 1 … 1 R PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module @classCode cs 1 … 1 F DOCBODY @moodCode cs 1 … 1 F EVN hl7:component 0 … 1 R The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, clinical laboratory data, specimen(s) description, collection procedure, reason for anatomic pathology procedure. Contains 1.3.6.1.4.1.19376.1.8.1.2.1 Clinical Information Section (2014‑05‑13 14:38:08) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module where [@typeCode='COMP'] [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.2.1']]] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R Contains 1.3.6.1.4.1.19376.1.8.1.2.2 Intraoperative Observation Section (2014‑05‑13 19:29:16) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module where [@typeCode='COMP'] [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.2.2']]] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R The Macroscopic Observation section contains the description of the specimen 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. Contains 1.3.6.1.4.1.19376.1.8.1.2.3 Macroscopic Observation Section (2014‑05‑13 11:57:09) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module where [@typeCode='COMP'] [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.2.3']]] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R 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. Contains 1.3.6.1.4.1.19376.1.8.1.2.4 Microscopic Observation Section (2014‑05‑13 14:25:17) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module where [@typeCode='COMP'] [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.2.4']]] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R The Additional Specific Observation section includes additional pathologic finding(s) and the results of ancillary study(ies) with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken.  Contains 1.3.6.1.4.1.19376.1.3.10.3.1 Additional Specified Observation Section (2016‑11‑13 14:28:08) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module where [@typeCode='COMP'] [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.3.1']]] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 1 … 1 M 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. Contains 1.3.6.1.4.1.19376.1.8.1.2.5 Diagnostic Conclusion Section (2014‑05‑13 19:31:26) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module where [@typeCode='COMP'] [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.2.5']]] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true hl7:component 0 … 1 R 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. Contains 1.3.6.1.4.1.19376.1.8.1.2.6 Procedure Steps Section (2014‑05‑13 19:33:12) PaLM Suppl. APSR 2.0‑3: 6.3.1.1 APSR clinical document content module where [@typeCode='COMP'] [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.2.6']]] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 1 … 1 F true

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.

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.

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 entries for this section are the Problem Organizer Entry module and the Update Information Organizer Entry module.

6.3.4.1.2 Specification and Example

Id	1.3.6.1.4.1.19376.1.8.1.2.1	Effective Date	valid from 2014‑05‑13 14:38:08
Status	Draft	Version Label	2.0
Name	ClinicalInformationSection	Display Name	Clinical 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).
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.1
Label	PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
Classification	CDA Section Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 1 template, Uses 5 templates Used by as Name Version 1.3.6.1.4.1.19376.1.8.1.1.1 Containment Anatomic Pathology Structured Report Content Module (2.0) 2014‑05‑13 11:57:57 Uses as Name Version 1.3.6.1.4.1.19376.1.8.1.3.6 Containment Problem Organizer (2.0) 2015‑08‑13 10:24:55 1.3.6.1.4.1.19376.1.8.1.4.2 Include CDA author IHE 2016‑06‑21 14:02:11 1.3.6.1.4.1.19376.1.5.3.1.3.1 Containment IHE Reason for Referral Section (2014) 2016‑09‑26 07:58:18 1.3.6.1.4.1.19376.1.5.3.1.3.4 Containment IHE History of Present Illness Section (2014) 2013‑01‑31 1.3.6.1.4.1.19376.1.5.3.1.3.6 Containment IHE Active Problems Section (2014) 2015‑10‑05 16:02:07
Relationship	Specialization: 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>
Item DT Card Conf Description Label hl7:section 0 … 1 R PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section @classCode cs 0 … 1 F DOCSECT @moodCode cs 0 … 1 F EVN   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. hl7:templateId II 1 … 1 R PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.2.1 hl7:code CE 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section @code CONF 1 … 1 F 22636-5 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) @codeSystemName 1 … 1 F LOINC @displayName 1 … 1 F Pathology report relevant history hl7:title ST 1 … 1 R PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section   CONF element content shall be "CLINICAL INFORMATION SECTION"   Example <title>CLINICAL INFORMATION</title> hl7:text SD.TEXT 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section   Example <text> Tissue submitted: left breast biopsy and apical axillary tissue </text> hl7:language​Code CS 0 … 1 PaLM 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) hl7:entry ANY 0 … * R Problem 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 where [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]] @typeCode cs 0 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true Included 0 … * 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 hl7:author 0 … * C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @typeCode cs 1 … 1 F AUT   Example author is a person <author typeCode="AUT" contextControlCode="OP">   <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">     <!-- ... -->   </assignedAuthor></author> hl7:templateId 1 … 1 M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.4.2 hl7:time TS 1 … 1 M The 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 hl7:assignedAuthor 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F ASSIGNED hl7:id II 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Choice 1 … 1 The author is either an assigned person or an authoring device. Elements to choose from: hl7:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Included 0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07) The name(s) SHALL be given. @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:softwareName SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:represented​Organization 0 … 1 PaLM 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> Included 0 … 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. @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:asOrganizationPartOf 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F PART hl7:id II 0 … * R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.111 (Role Code) hl7:statusCode CS 0 … 1 PaLM 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) hl7:effectiveTime IVL_TS 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:wholeOrganization 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:component 0 … 1 Subsection 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 where [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.5.3.1.3.1']]] hl7:component 0 … 1 Subsection 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 where [hl7:section [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.5.3.1.3.4']]] hl7:component 0 … 1 Subsection 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 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

Id	1.3.6.1.4.1.19376.1.8.1.2.2	Effective Date	valid from 2014‑05‑13 19:29:16
Status	Draft	Version Label	2.0
Name	IntraoperativeObservationSection	Display Name	Intraoperative 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).
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.2
Label	PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section
Classification	CDA Section Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 1 template, Uses 2 templates Used by as Name Version 1.3.6.1.4.1.19376.1.8.1.1.1 Containment Anatomic Pathology Structured Report Content Module (2.0) 2014‑05‑13 11:57:57 Uses as Name Version 1.3.6.1.4.1.19376.1.8.1.4.2 Include CDA author IHE 2016‑06‑21 14:02:11 1.3.6.1.4.1.19376.1.8.1.3.6 Containment Problem Organizer (2.0) 2015‑08‑13 10:24:55
Relationship	Specialization: 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>
Item DT Card Conf Description Label hl7:section 0 … 1 R PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section @classCode cs 1 … 1 F DOCSECT @moodCode cs 1 … 1 F EVN   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. hl7:templateId II 1 … 1 R PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.2.2 hl7:code CE 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section @code CONF 1 … 1 F 83321-0 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) @codeSystemName 1 … 1 F LOINC @displayName 1 … 1 F Pathology report intraoperative observation in Specimen Document hl7:title ST 1 … 1 R PaLM Suppl. 2.0‑3: 6.3.4.2 Intraoperative observation section   CONF element content shall be "INTRAOPERATIVE OBSERVATION SECTION" hl7:text SD.TEXT 1 … 1 M PaLM 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> hl7:language​Code CS 0 … 1 PaLM 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) Included 0 … * 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 hl7:author 0 … * C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @typeCode cs 1 … 1 F AUT   Example author is a person <author typeCode="AUT" contextControlCode="OP">   <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">     <!-- ... -->   </assignedAuthor></author> hl7:templateId 1 … 1 M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.4.2 hl7:time TS 1 … 1 M The 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 hl7:assignedAuthor 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F ASSIGNED hl7:id II 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Choice 1 … 1 The author is either an assigned person or an authoring device. Elements to choose from: hl7:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Included 0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07) The name(s) SHALL be given. @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:softwareName SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:represented​Organization 0 … 1 PaLM 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> Included 0 … 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. @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:asOrganizationPartOf 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F PART hl7:id II 0 … * R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.111 (Role Code) hl7:statusCode CS 0 … 1 PaLM 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) hl7:effectiveTime IVL_TS 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:wholeOrganization 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:entry 0 … * R Source: 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 where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true

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

Id	1.3.6.1.4.1.19376.1.8.1.2.3	Effective Date	valid from 2014‑05‑13 11:57:09
Status	Draft	Version Label	2.0
Name	MacroscopySection	Display Name	Macroscopic 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.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.3
Label	PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
Classification	CDA Section Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 1 template, Uses 2 templates Used by as Name Version 1.3.6.1.4.1.19376.1.8.1.1.1 Containment Anatomic Pathology Structured Report Content Module (2.0) 2014‑05‑13 11:57:57 Uses as Name Version 1.3.6.1.4.1.19376.1.8.1.4.2 Include CDA author IHE 2016‑06‑21 14:02:11 1.3.6.1.4.1.19376.1.8.1.3.6 Containment Problem Organizer (2.0) 2015‑08‑13 10:24:55
Relationship	Specialization: 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>
Item DT Card Conf Description Label hl7:section 0 … 1 R PaLM 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. hl7:templateId II 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.2.3 hl7:code CE 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section @code CONF 1 … 1 F 22634-0 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) @codeSystemName 1 … 1 F LOINC @displayName 1 … 1 F Pathology report gross observation hl7:title ST 1 … 1 R PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section   CONF element content shall be "MACROSCOPIC OBSERVATION SECTION"   Example <title>Macroscopic Observation</title> hl7:text SD.TEXT 1 … 1 M PaLM 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> Included 0 … * 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 hl7:author 0 … * C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @typeCode cs 1 … 1 F AUT   Example author is a person <author typeCode="AUT" contextControlCode="OP">   <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">     <!-- ... -->   </assignedAuthor></author> hl7:templateId 1 … 1 M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.4.2 hl7:time TS 1 … 1 M The 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 hl7:assignedAuthor 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F ASSIGNED hl7:id II 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Choice 1 … 1 The author is either an assigned person or an authoring device. Elements to choose from: hl7:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Included 0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07) The name(s) SHALL be given. @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:softwareName SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:represented​Organization 0 … 1 PaLM 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> Included 0 … 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. @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:asOrganizationPartOf 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F PART hl7:id II 0 … * R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.111 (Role Code) hl7:statusCode CS 0 … 1 PaLM 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) hl7:effectiveTime IVL_TS 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:wholeOrganization 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:entry 0 … * R 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: 6.3.4.3 Macroscopic observation section where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true

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

Id	1.3.6.1.4.1.19376.1.8.1.2.4	Effective Date	valid from 2014‑05‑13 14:25:17
Status	Draft	Version Label	2.0
Name	MicroscopySection	Display Name	Microscopic 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.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.4
Label	PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section
Classification	CDA Section Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 1 template, Uses 2 templates Used by as Name Version 1.3.6.1.4.1.19376.1.8.1.1.1 Containment Anatomic Pathology Structured Report Content Module (2.0) 2014‑05‑13 11:57:57 Uses as Name Version 1.3.6.1.4.1.19376.1.8.1.4.2 Include CDA author IHE 2016‑06‑21 14:02:11 1.3.6.1.4.1.19376.1.8.1.3.6 Containment Problem Organizer (2.0) 2015‑08‑13 10:24:55
Relationship	Specialization: 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>
Item DT Card Conf Description Label hl7:section 0 … 1 R PaLM 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.  hl7:templateId II 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.2.4 hl7:code CE 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.4 Microscopic observation section @code CONF 1 … 1 F 22635-7 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) @codeSystemName 1 … 1 F LOINC @displayName 1 … 1 F Pathology report microscopic observation hl7:title ST 1 … 1 R PaLM 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> hl7:text SD.TEXT 1 … 1 M PaLM 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> Included 0 … * 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 hl7:author 0 … * C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @typeCode cs 1 … 1 F AUT   Example author is a person <author typeCode="AUT" contextControlCode="OP">   <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">     <!-- ... -->   </assignedAuthor></author> hl7:templateId 1 … 1 M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.4.2 hl7:time TS 1 … 1 M The 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 hl7:assignedAuthor 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F ASSIGNED hl7:id II 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Choice 1 … 1 The author is either an assigned person or an authoring device. Elements to choose from: hl7:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Included 0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07) The name(s) SHALL be given. @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:softwareName SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:represented​Organization 0 … 1 PaLM 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> Included 0 … 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. @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:asOrganizationPartOf 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F PART hl7:id II 0 … * R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.111 (Role Code) hl7:statusCode CS 0 … 1 PaLM 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) hl7:effectiveTime IVL_TS 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:wholeOrganization 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:entry 0 … * R Problem 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 where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true

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. Further CDA content section modules as subsections are allowed. The only entries for this section are the Problem Organizer Entry module and the Update Information Organizer Entry module.

6.3.4.5.2 Specification and Example

Id	1.3.6.1.4.1.19376.1.3.10.3.1	Effective Date	valid from 2016‑11‑13 14:28:08
Status	Draft	Version Label	2.0
Name	AdditionalSpecifiedObservationSection	Display Name	Additional 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.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.3.1
Label	PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section
Classification	CDA Section Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 1 template, Uses 2 templates Used by as Name Version 1.3.6.1.4.1.19376.1.8.1.1.1 Containment Anatomic Pathology Structured Report Content Module (2.0) 2014‑05‑13 11:57:57 Uses as Name Version 1.3.6.1.4.1.19376.1.8.1.4.2 Include CDA author IHE 2016‑06‑21 14:02:11 1.3.6.1.4.1.19376.1.8.1.3.6 Containment Problem Organizer (2.0) 2015‑08‑13 10:24:55
Relationship	Adaptation: 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>
Item DT Card Conf Description Label hl7:section 0 … * R PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section @classCode cs 0 … 1 F DOCSECT @moodCode cs 0 … 1 F EVN   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.  hl7:templateId II 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.10.3.1 hl7:code CE 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section   Constraint The LOINC code SHALL be chosen according the specified observation type @code CONF 1 … 1 F xxxxx-x @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) @codeSystemName 1 … 1 F LOINC @displayName 1 … 1 F specified observation hl7:title ST 1 … 1 R Title of the specified observation PaLM 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> hl7:text SD.TEXT 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.5 Addtional specified observation section Included 0 … * 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  hl7:author 0 … * C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @typeCode cs 1 … 1 F AUT   Example author is a person <author typeCode="AUT" contextControlCode="OP">   <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">     <!-- ... -->   </assignedAuthor></author> hl7:templateId 1 … 1 M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.4.2 hl7:time TS 1 … 1 M The 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 hl7:assignedAuthor 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F ASSIGNED hl7:id II 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Choice 1 … 1 The author is either an assigned person or an authoring device. Elements to choose from: hl7:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author Included 0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07) The name(s) SHALL be given. @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:softwareName SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:represented​Organization 0 … 1 PaLM 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> Included 0 … 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.