1.3.6.1.4.1.19376.1.3.10.4.1/static-2014-07-29T160202

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Id1.3.6.1.4.1.19376.1.3.10.4.1Effective Date2014‑07‑29 16:02:02
Other versions this id:
  • Kblank.png SpecimenProcedureStep as of 2016‑07‑08 13:20:59
StatusKcancelledblue.png CancelledVersion Label1.0
NameSpecimenProcedureStepDisplay NameSpecimen Procedure Step
Description
Template CDA Procedure (prototype, directly derived from POCD_RM000040 MIF)
All procedures, done on a specimen from collection through all work order steps in APW for identification of the hierarchy of all specimen related IDs
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.1
ClassificationCDA Entry Level Template
Open/ClosedClosed (only defined elements are allowed)
Uses
Uses 4 templates
Uses as NameVersion
2.16.840.1.113883.10.12.322ContainmentKgreen.png CDA SpecimenDYNAMIC
2.16.840.1.113883.10.12.323ContainmentKgreen.png CDA Performer (Body)DYNAMIC
1.3.6.1.4.1.19376.1.3.10.4.2ContainmentKyellow.png UICC/AJCC TNM Staging and Grading Observation (2.0)DYNAMIC
1.3.6.1.4.1.19376.1.3.10.4.1ContainmentKyellow.png Specimen Procedure Step (2.0)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.306 CDA Procedure (2005‑09‑07)
ref
ad1bbr-
Example
Specimen procedure step entry
<procedure classCode="PROC" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.4.11"/>  <templateId root="1.3.6.1.4.1.19376.1.8.1.4.28"/>  <!-- type of the procedure step, here collection -->
  <code code="432550005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Core needle biopsy of breast using ultrasound guidance (procedure)">
    <originalText>
      <reference value="#A7102400008"/>    </originalText>
  </code>
  <effectiveTime/>  <!-- Anatomic site -->
  <targetSiteCode code="664" codeSystem="1.3.6.1.4.1.19376.1.8.2.1" displayName="Lower outer quadrant" codeSystemName="PATHLEX">
    <qualifier>
      <name code="272741003" codeSystem="2.16.840.1.113883.6.96" displayName="laterality" codeSystemName="SNOMED-CT"/>      <value code="24028007" codeSystem="2.16.840.1.113883.6.96" displayName="right" codeSystemName="SNOMED-CT"/>    </qualifier>
  </targetSiteCode>
  <!-- Specimen collector: the surgeon in this case -->
  <performer/>  <!-- the specimen collected -->
  <participant typeCode="PRD">
    <participantRole classCode="SPEC">
      <!-- specimen id -->
      <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="A7102400008"/>      <playingEntity>
        <!-- need a code in PATHLEX for "part obtained from a biopsy -->
        <code code="373102004" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen from breast obtained by image guided core biopsy (specimen)" codeSystemName="SNOMED CT"/>      </playingEntity>
    </participantRole>
  </participant>
  <!-- Child procedure step: Production of block A1 -->
  <entryRelationship typeCode="COMP">
    <procedure classCode="PROC" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.8.1.4.11"/>      <templateId root="1.3.6.1.4.1.19376.1.8.1.4.28"/>      <!-- type of the procedure step, here sampling a tissue dice from the part for a block -->
      <code code="433465004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Sampling of tissue specimen (procedure)">
        <originalText>
          <reference value="#block_A_1"/>        </originalText>
      </code>
      <effectiveTime/>      <targetSiteCode code="85756007" codeSystem="2.16.840.1.113883.6.96" displayName="Body tissue structure (body structure)" codeSystemName="SNOMED CT">
        <qualifier>
          <!-- a series of codes in PATHLEX would help to describe the exact topographic source of the tissue obtained by trimming and sampling -->
          <name code="118169006" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen source topography (attribute)" codeSystemName="SNOMED-CT"/>          <value code="255503000" codeSystem="2.16.840.1.113883.6.96" displayName="Entire (qualifier value)" codeSystemName="SNOMED-CT"/>        </qualifier>
      </targetSiteCode>
      <!-- Specimen preparator: a member staff of the pathology lab -->
      <Performer/>      <!-- the specimen produced -->
      <participant typeCode="PRD">
        <participantRole classCode="SPEC">
          <!-- specimen ids -->
          <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="block_A_1"/>          <parentId root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="A7102400008"/>          <playingEntity>
            <!-- need a code in PATHLEX for "block extracted from a part -->
            <code code="441652008" codeSystem="2.16.840.1.113883.6.96" displayName="Formalin-fixed paraffin-embedded tissue specimen (specimen)" codeSystemName="SNOMED CT"/>          </playingEntity>
        </participantRole>
      </participant>
    </procedure>
  </entryRelationship>
</procedure>
ItemDTCardConfDescriptionLabel
hl7:procedure
0 … *(Spe...tep)
Treetree.png@classCode
cs1 … 1FPROC
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1R(Spe...tep)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.12.306
Treetree.pnghl7:id
II1 … 1R(Spe...tep)
Treetree.pnghl7:code
CD1 … 1R(Spe...tep)
 ConstraintDE-DE.png for specimen collection procedure codes for targetSite or PathLex or SNOMED CT have to be used, for specimen processing (down step the procedures) SNOMED CT is preferred, DICOM could be used if available
 CONF
@code shall be "17636008"
@codeSystem shall be "2.16.840.1.113883.6.96"
@displayName shall be "Specimen collection (procedure)"
@codeSystemName shall be "SNOMED CT"
or
@code shall be "40923002"
@codeSystem shall be "2.16.840.1.113883.6.96"
@displayName shall be "Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)"
@codeSystemName shall be "SNOMED CT"
Treetree.pnghl7:text
ED0 … 1(Spe...tep)
 Example
specimen collection procedure
<text>ULTRASOUND GUIDED NEEDLE CORE BIOPSY</text>
 Example
specimen processing procedure
<text>CUTTING A SLIDE FROM A PARAFFIN BLOCK</text>
Treetree.pnghl7:statusCode
CS0 … 1(Spe...tep)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS0 … 1(Spe...tep)
Treetree.pnghl7:methodCode
CE0 … *(Spe...tep)
 CONF
@codeSystem shall be "2.16.840.1.113883.5.1065"
or
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.10 Specimen Collection and Processing (DYNAMIC)
Treetree.pnghl7:target​Site​Code
CD0 … *(Spe...tep)
 CONF
@codeSystem shall be "2.16.840.1.113883.5.1052"
or
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.9 Procedure Site (DYNAMIC)
Treetree.pnghl7:performer
0 … *Contains 2.16.840.1.113883.10.12.322 CDA Specimen (DYNAMIC)(Spe...tep)
Treetree.pnghl7:author
0 … *Contains 2.16.840.1.113883.10.12.323 CDA Performer (Body) (DYNAMIC)(Spe...tep)
Treetree.pnghl7:participant
1 … 1MContains 1.3.6.1.4.1.19376.1.3.10.4.2 UICC/AJCC TNM Staging and Grading Observation (DYNAMIC)(Spe...tep)
 Example
Specimen collected or processed
<participant typeCode="PRD">
  <participantRole classCode="SPEC">
    <!-- specimen ids -->
    <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="A7102400008"/>    <playingEntity>
      <!-- need a code in PATHLEX for "part obtained from a biopsy -->
      <code code="theCode" codeSystem="1.3.6.1.4.1.19376.1.8.2.1" displayName="part collected by biopsy" codeSystemName="PATHLEX"/>    </playingEntity>
  </participantRole>
</participant>
Treetree.pnghl7:entryRelationship
0 … 2Contains 1.3.6.1.4.1.19376.1.3.10.4.1 Specimen Procedure Step (DYNAMIC)(Spe...tep)