1.3.6.1.4.1.19376.1.3.10.4.1/static-2016-07-08T132059

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Id1.3.6.1.4.1.19376.1.3.10.4.1Effective Date2016‑07‑08 13:20:59
Other versions this id:
  • Kblank.png SpecimenProcedureStep as of 2014‑07‑29 16:02:02
StatusKyellow.png DraftVersion Label2.0
NameSpecimenProcedureStepDisplay NameSpecimen Procedure Step
Description
Template CDA Procedure (prototype, directly derived from POCD_RM000040 MIF)
for Specimen procedure step in APSR 2.

This entry collects all the information of source, method and outcome of a specimen procedure from the collection out of the patient through the final product of a stained histologic section or cytologic smear on a glass slide, or a WSI of such a slide. It reflects the workflow and the probe tracking of a pathology laboratory.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.1
LabelPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 7 concepts
IdNameData Set
psr-data​element-24Kyellow.png Specimen collection Kyellow.png APSR 2.0
psr-data​element-25Kyellow.png Specimen processing Kyellow.png APSR 2.0
psr-data​element-101Kyellow.png Work order step Kyellow.png APSR 2.0
psr-data​element-94Kyellow.png Target Site Kyellow.png APSR 2.0
psr-data​element-90Kyellow.png Requested Procedure Kyellow.png APSR 2.0
psr-data​element-89Kyellow.png Procedure Step Kyellow.png APSR 2.0
psr-data​element-87Kyellow.png Procedure ID Kyellow.png APSR 2.0
Uses
Uses 7 templates
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified (2.0)2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png Author (2.0)2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.3.10.9.44ContainmentKyellow.png CDA Participant (Body) Procedure Steps APSR2 (2.0)2014‑10‑26 17:06:28
1.3.6.1.4.1.19376.1.3.10.9.22ContainmentKyellow.png Specimen Container in Procedure Step (2.0)2016‑07‑29 12:09:33
1.3.6.1.4.1.19376.1.3.1.3ContainmentKgreen.png Specimen Received (2017)2008‑08‑08
2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA Reference2005‑09‑07
RelationshipAdaptation: template 2.16.840.1.113883.10.12.306 CDA Procedure (2005‑09‑07)
ref
ad1bbr-
Example
example for use case #1, Sectioning and ER-Immuno-Staining
<procedure negationInd="false" classCode="PROC" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.4.1"/>  <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008-P4"/>  <code code="117617002" codeSystem="2.16.840.1.113883.6.96" displayName="Immunohistochemistry procedure (procedure)">
    <qualifier>
      <name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/>      <value code="23307004" displayName="Estrogen receptor (substance)" codeSystem="2.16.840.1.113883.6.96"/>    </qualifier>
  </code>
  <statusCode code="completed"/>  <effectiveTime>
    <low value="201001030925-0500"/>  </effectiveTime>
  <targetSiteCode code="441652008" codeSystem="2.16.840.1.113883.6.96" displayName="Formalin-fixed paraffin-embedded tissue specimen (specimen)"/>  <!-- PARENT SPECIMEN on which the procedure step is performed -->
  <specimen typeCode="SPC">
    <specimenRole classCode="SPEC">
      <!-- Parent specimen ID -->
      <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_block_A_1"/>    </specimenRole>
  </specimen>
  <!-- Specimen processor: the lab technician in this case -->
  <performer typeCode="PRF">
    <time>
      <low value="201001030925-0500"/>    </time>
    <modeCode code="PHYSICAL" displayName="physical presence" codeSystem="2.16.840.1.113883.5.1064"/>    <assignedEntity>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="member#32"/>      <assignedPerson>
        <name>
          <given>John</given>          <family>Labtech</family>        </name>
      </assignedPerson>
    </assignedEntity>
  </performer>
  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->
  </author>
  <!--Product of the procedure, i.e. specimen -->
  <participant typeCode="PRD" contextControlCode="OP">
    <time>
      <low value="201001030925-0500"/>    </time>
    <!-- ID of the specimen produced, coming from the LIS -->
    <participantRole classCode="SPEC">
      <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_slide_A_1_ER"/>      <code code="P" codeSystem="2.16.840.1.113883.5.111"/>      <playingEntity classCode="ENT" determinerCode="INSTANCE">
        <code code="TISS" displayName="Tissue, unspecified" codeSystem="2.16.840.1.113883.5.1060"/>        <quantity value="1"/>        <desc/>      </playingEntity>
    </participantRole>
  </participant>
  <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">
    <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.22 'CDA Supply Container APSR2' (2016-07-29T12:09:33) -->
  </entryRelationship>
  <entryRelationship typeCode="COMP" inversionInd="false" contextConductionInd="true" negationInd="false">
    <act classCode="ACT" moodCode="EVN" negationInd="false">
      <templateId root="1.3.6.1.4.1.19376.1.3.1.3"/>      <code code="SPRECEIVE" codeSystem="1.3.5.1.4.1.19376.1.5.3.2" displayName="Specimen received" codeSystemName="IHEActCode"/>      <effectiveTime>
        <low value="201001030925-0500"/>      </effectiveTime>
    </act>
  </entryRelationship>
  <entryRelationship typeCode="REFR" inversionInd="false" contextConductionInd="true" negationInd="false">
    <seperatableInd value="false"/>    <procedure classCode="PROC" moodCode="EVN" negationInd="false">
      <!-- ID of the child procedure, coming from LIS -->
      <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008-P5"/>    </procedure>
  </entryRelationship>
</procedure>
ItemDTCardConfDescriptionLabel
hl7:procedure
0 … *RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
 
Target.png
psr-data​element-24Kyellow.png Specimen collection Kyellow.png APSR 2.0
psr-data​element-25Kyellow.png Specimen processing Kyellow.png APSR 2.0
psr-data​element-101Kyellow.png Work order step Kyellow.png APSR 2.0
psr-data​element-90Kyellow.png Requested Procedure Kyellow.png APSR 2.0
Treetree.png@classCode
cs1 … 1FPROC
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.4.1
Treetree.pnghl7:id
II0 … *RProcedure ID, coming from the LIS.
May be the target (referenced) ID for the child procedure.
PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
 
Target.png
psr-data​element-89Kyellow.png Procedure Step Kyellow.png APSR 2.0
psr-data​element-87Kyellow.png Procedure ID Kyellow.png APSR 2.0
Treetree.pnghl7:code
CD (extensible)1 … 1MCoded procedurePaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
 Constraintfor specimen collection procedure codes for targetSite or SNOMED CT have to be used, for specimen processing (down step the procedures) SNOMED CT is preferred, DICOM could be used if available
 CONF
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.10 Specimen Collection and Processing (2016‑05‑31 15:09:59)
 Example
for use case #1, specimen collection
<code code="122548005" codeSystem="2.16.840.1.113883.6.96" displayName="Biopsy of breast (procedure)" codeSystemName="SNOMED-CT"/>
 Example
for use case #1, grossing & embedding
<code code="40923002" codeSystem="2.16.840.1.113883.6.96" displayName="Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)"/>
 Example
for use case #1, sectioning & immunostaining
<code code="117617002" codeSystem="2.16.840.1.113883.6.96" displayName="Immunohistochemistry procedure (procedure)"/>
Treeblank.pngTreetree.pnghl7:qualifier
CR (extensible)0 … *CQualifier for staining or other procedures which don´t have values in the vocabulary used.PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
 ConstraintUsed only in staining and other procedures without values in SCT or LOINC or DICOM vocabulary, e.g. immune stains
 Example
for use case #1, grossing & embedding
<qualifier>
  <name code="246355002" displayName="Supporting structure (attribute)" codeSystem="2.16.840.1.113883.6.96"/>  <value code="702941008" displayName="Paraffin embedding (qualifier value)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/></qualifier>
 Example
for use case #1, Estrogen receptor staining
<qualifier>
  <name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/>  <value code="23307004" displayName="Estrogen receptor (substance)" codeSystem="2.16.840.1.113883.6.96"/></qualifier>
 Example
for use case #1, ISH Her-2-neu staining
<qualifier>
  <name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/>  <value code="164870" displayName="ONCOGENE ERBB2" codeSystem="2.16.840.1.113883.6.174" codeSystemName="OMIM"/></qualifier>
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV (extensible)1 … 1RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs0 … 1F246094008_or_246355002
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid0 … 1F2.16.840.1.113883.6.96
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st0 … 1FComponent investigated (attribute) or Supporting structure (attribute)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD (extensible)1 … 1RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs1 … 1R
 CONF
@code shall be "<<105590001 | Substance (substance) |"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SNOMED-CT"
@displayName shall be "values from substance axis, e.g. Estrogen receptor"
or
@code shall be "values from G axis"
@codeSystem shall be "2.16.840.1.113883.6.174"
@codeSystemName shall be "OMIM"
@displayName shall be "values from G axis, e.g. erb-b2"
or
@code shall be "<<272394005 | Technique (qualifier value) |"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SNOMED-CT"
@displayName shall be "values from technique axis, e.g. Paraffin embedded (qualifier)"
Treetree.pnghl7:text
ED0 … 1RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
 Example
specimen collection procedure
<text>ULTRASOUND GUIDED NEEDLE CORE BIOPSY</text>
 Example
specimen processing procedure
<text>CUTTING A SLIDE FROM A PARAFFIN BLOCK</text>
Treetree.pnghl7:statusCode
CS (required)0 … 1RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS0 … 1RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
Treetree.pnghl7:approachSiteCode
CD (extensible)0 … 1RApproach site in specimen collectionPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
Treeblank.pngTreetree.png@code
CONF0 … 1Fany_code
Treeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.5.1052 (Act Site)
Treeblank.pngTreetree.png@codeSystemName
0 … 1Fany_code
Treeblank.pngTreetree.png@displayName
0 … 1FActSite
Treetree.pnghl7:target​Site​Code
CD (extensible)0 … 1RTarget site in body or relative parent relationship in case of specimen processingPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
 
Target.png
psr-data​element-94Kyellow.png Target Site Kyellow.png APSR 2.0
 CONF
@code shall be "<<123037004 | Body structure (body structure) |"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SCT"
@displayName shall be "all children of Body structure (body structure)"
or
@code shall be "any_code"
@codeSystem shall be "2.16.840.1.113883.5.1052"
@codeSystemName shall be "ActSite"
@displayName shall be "any_code"
or
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.9 Procedure Site (2016‑06‑01 18:46:15)
 Example
for use case #1, specimen collection
<targetSiteCode code="110497008" displayName="Lower outer quadrant of right breast (body structure)" codeSystem="2.16.840.1.113883.6.96"/>
 Example
for use case #1, grossing & embedding
<targetSiteCode code="309050000" displayName="Body substance sample" codeSystem="2.16.840.1.113883.6.96"/>
Treeblank.pngTreetree.pnghl7:qualifier
CR (extensible)0 … *Coptional qualifiers for specifying body structures or / and lateralityPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
 Example
for use case #1, (optional) specification of body structure for specimen collection
<qualifier>
  <name code="118169006" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen source topography (attribute)" codeSystemName="SNOMED-CT"/>  <value code="255495000" codeSystem="2.16.840.1.113883.6.96" displayName="Right lower quadrant (qualifier value)" codeSystemName="SNOMED-CT"/></qualifier>
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV (extensible)1 … 1RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
st0 … 1FSpecimen source topography
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
oid1 … 1F2.16.840.1.113883.6.96
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs1 … 1F118169006
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD (extensible)0 … *RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF0 … 1F<<272099008
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.6.96 (Snomed-CT)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
0 … 1FSCT
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
0 … 1Fall children of Descriptor (qualifier values) e.g. right lower quadrant
Treetree.pnghl7:methodCode
CD (extensible)0 … *RIdentifies the technique used to perform a procedurePaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
Treeblank.pngTreetree.png@codeSystem
cs1 … 1F2.16.840.1.113883.5.1065
Included0 … 1R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Parent specimen with parent ID
 Example
for use case #1, parent specimen ID in grossing & embedding
<specimen typeCode="SPC">
  <specimenRole classCode="SPEC">
    <!-- Parent specimen ID -->
    <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008"/>  </specimenRole>
</specimen>
Treetree.pnghl7:specimen
0 … 1RRequired in XD-LAB when more than one specimen is documented at this level. Always required in APSR.PaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified
 
Target.png
psr-data​element-17Kyellow.png Specimen identification Kyellow.png APSR 2.0
Treeblank.pngTreetree.png@typeCode
cs0 … 1FSPC
Treeblank.pngTreetree.pnghl7:specimenRole
1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FSPEC
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified
 
Target.png
psr-data​element-95Kyellow.png Parent ID Kyellow.png APSR 2.0
psr-data​element-67Kyellow.png Block ID Kyellow.png APSR 2.0
psr-data​element-66Kyellow.png Part ID Kyellow.png APSR 2.0
psr-data​element-98Kyellow.png Specimen ID Kyellow.png APSR 2.0
psr-data​element-68Kyellow.png Tissue section ID Kyellow.png APSR 2.0
Treetree.pnghl7:performer
0 … 1RContains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
Treetree.pnghl7:author
0 … *CContains 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11)PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
Treetree.pnghl7:participant
1 … *MOne or more specimen (with additives), which participates as product of the procedure
Contains 1.3.6.1.4.1.19376.1.3.10.9.44 CDA Participant (Body) Procedure Steps APSR2 (2014‑10‑26 17:06:28)
PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
Treetree.pnghl7:entryRelationship
0 … *RSpecimen container (manufactured product)
Contains 1.3.6.1.4.1.19376.1.3.10.9.22 Specimen Container in Procedure Step (2016‑07‑29 12:09:33)
PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
 Constraintfor manufactured product
classCode = MANU

for DrugOrOtherMaterial
classCode = MMAT
code from MaterialEntityClassType
Treetree.pnghl7:entryRelationship
0 … 1RSpecimen arrival in Lab
Contains 1.3.6.1.4.1.19376.1.3.1.3 Specimen Received (2008‑08‑08)
PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:entryRelationship
0 … *RReferencing mechanism to the ID of the child procedures, giving a lis of child procedure IDsPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFR
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
 Constraintcontains only ID(s) of the child procedure(s), which is(are) fully described in dedicated entry(s) further down in the Procedure step section.
Treeblank.pngTreetree.pnghl7:procedure
1 … 1RChild procedurePaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FPROC
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 … 1FEVN
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *RID of the child procedure, coming from the LIS.PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
Treetree.pnghl7:reference
0 … *RReference to an external document, or to external procedures, e.g. concerning molecular pathology or  genetic testing report
Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)
PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps