1.3.6.1.4.1.19376.1.3.10.3.1

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Template:Templatenote

Template AdditionalSpecifiedObservationSection

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. 

Actual version

Id1.3.6.1.4.1.19376.1.3.10.3.1Effective Date2016‑11‑13 14:28:08
StatusKyellow.png DraftVersion Label2.0
NameAdditionalSpecifiedObservationSectionDisplay NameAdditional Specified Observation Section
Description
Template CDA Section (prototype, directly derived from POCD_RM000040 MIF)

The Additional Specified Observation section includes additional pathologic finding(s) and the results of ancillary study(yes) with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken.  Further CDA content section modules as subsections are allowed. 
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.3.1
LabelPaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 1 concept
IdNameData Set
psr-data​element-96Kyellow.png Additional Specified Observation Kyellow.png APSR 2.0
Uses
Uses 2 templates
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png Author (2.0)2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
RelationshipAdaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
Example
generated example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.3.1"/>  <code code="xxxxx-x" codeSystem="2.16.840.1.113883.6.1" displayName="specified observation"/>  <title>ADDITIONAL SPECIFIED OBSERVATION SECTION</title>  <text/>  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016‑06‑21 14:02:11) -->
  </author>
  <entry typeCode="COMP" contextConductionInd="true">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->
  </entry>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … *RPaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section
 
Target.png
psr-data​element-96Kyellow.png Additional Specified Observation Kyellow.png APSR 2.0
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.png@moodCode
cs0 … 1FEVN
 Constraint

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

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

@codeSystem="2.16.840.1.113883.6.1" 

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

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

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

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

This section MAY contain subsections. 

Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.3.1
Treetree.pnghl7:code
CE1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section
 ConstraintThe LOINC code SHALL be chosen according the specified observation type
Treeblank.pngTreetree.png@code
CONF1 … 1Fxxxxx-x
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1Fspecified observation
Treetree.pnghl7:title
ST1 … 1RPaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section
 Example
MP observation
<text>MOLECULAR PATHOLOGY OBSERVATION SECTION</text>
Treetree.pnghl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11)
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2 
Treetree.pnghl7:author
0 … *CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
 
Target.png
psr-data​element-4Kyellow.png Pathologist Kyellow.png APSR 2.0
psr-data​element-79Kyellow.png Device Kyellow.png APSR 2.0
Treeblank.pngTreetree.png@typeCode
cs1 … 1FAUT
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor>
</author>
Treeblank.pngTreetree.pnghl7:templateId
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
Treeblank.pngTreetree.pnghl7:time
TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreetree.pnghl7:assignedAuthor
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
 
Target.png
psr-data​element-18Kyellow.png Address Kyellow.png APSR 2.0
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Choice1 … 1
The author is either an assigned person or an authoring device.
Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
 
Target.png
psr-data​element-5Kyellow.png Name Kyellow.png APSR 2.0
Included1 … 1R from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
The name(s) SHALL be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
 Example
represented organization for author as a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>
</representedOrganization>
Included0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)
The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given.
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standard​Industry​Class​Code
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPART
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
 CONF
shall be drawn from concept domain "RoleCode"
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
CS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standard​Industry​Class​Code
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treetree.pnghl7:entry
0 … *RSource: PaLM Suppl. APSR 2.0-3: 6.2.5.2
Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (2015‑08‑13 10:24:55)
PaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue


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