1.3.6.1.4.1.19376.1.3.10.4.3

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Template:Templatenote

Template ICD-O-3TypingGrading

Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF)Entry template for observation on ICD-O-3 Typing and Grading

Actual version

Id1.3.6.1.4.1.19376.1.3.10.4.3Effective Date2015‑11‑29 17:03:18
StatusKyellow.png DraftVersion Label2.0
NameICD-O-3TypingGradingDisplay NameICD-O-3 Typing and Grading Observation
DescriptionTemplate CDA Observation (prototype, directly derived from POCD_RM000040 MIF)

Entry template for observation on ICD-O-3 Typing and Grading
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.3
LabelPaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 1 concept
IdNameData Set
psr-data​element-54Kyellow.png Tumor classification (ICD-O-3) Kyellow.png APSR 2.0
Uses
Uses 9 templates
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png Author (2.0)2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png Informant (2.0)2016‑07‑08 11:22:58
1.3.6.1.4.1.19376.1.8.1.4.7ContainmentKyellow.png Additional participant in an entry (2.0)2016‑07‑12 18:44:06
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified (2.0)2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.3.10.9.38ContainmentKyellow.png ICD-O-3 Behavior (2.0)2015‑12‑03 09:11:54
1.3.6.1.4.1.19376.1.3.10.9.39ContainmentKyellow.png ICD-O-3 Differentiation (2.0)2015‑12‑09 17:12:30
1.3.6.1.4.1.19376.1.3.10.4.4ContainmentKyellow.png Assessment Scales Observation for Scoring Systems (2.0)2016‑10‑06 13:12:00
2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA Reference2005‑09‑07
RelationshipSpecialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54)
Example
example for use case #1
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.4.3"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_ICDO"/>  <code code="31205-8" codeSystem="2.16.840.1.113883.6.1" displayName="Histology ICD-O-3 Cancer"/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="201001041405-0500"/>  </effectiveTime>
  <value xsi:type="CD" code="8500/3" codeSystem="2.16.840.1.113883.6.43.1"/>  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->
  </author>
  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 1..* R -->
  <specimen typeCode="SPC">
    <specimenRole classCode="SPEC">
      <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_slide_A1_HE"/>    </specimenRole>
  </specimen>
  <entryRelationship typeCode="SPRT">
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.38 'ICD-O-3 Behavior' (2015-12-03T09:11:54), not used in use case #1 -->
  </entryRelationship>
  <entryRelationship typeCode="SPRT">
    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.39 'ICD-O-3 Differentiation' (2015-12-09T17:12:30) -->
  </entryRelationship>
  <entryRelationship typeCode="COMP">
    <!-- template 1.3.6.1.4.1.19376.1.3.10.4.4 'Assessment Scales Observation for Scoring Systems APSR2' (2016-10-06T13:12:00) -->
  </entryRelationship>
  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
  </reference>
</observation>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … 1RFirst four digits of Morphology axis code. A complete code consists of 6 digits (for morphology, behavior and grading), the latter both separated by "/" after the 4th digit in morphology.

Behavior and differentiation are coded as sub-observations
PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.4.3
Treetree.pnghl7:id
II0 … *RPaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3
Treetree.pnghl7:code
CV (extensible)1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3
 CONF
@code shall be "31205-8"
@codeSystem shall be "2.16.840.1.113883.6.1"
@codeSystemName shall be "LOINC"
@displayName shall be "Histology ICD-O-3 Cancer"
or
@code shall be "397005006"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SNOMED-CT"
@displayName shall be "WHO tumor classification (observable entity)"
Treetree.pnghl7:statusCode
CS (required)1 … 1MThe observation statusCode is “completed” if the observation was actually performed and has produced a result in the  value element. In other cases the status of the intended observation is “aborted” and the result will never come.PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3
 Constraint
@code shall be "completed"
or
@code shall be "aborted"
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (2014‑03‑26)
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3
Treetree.pnghl7:value
CD1 … 1RFirst four digits of Morphology axis codePaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3
 
Target.png
psr-data​element-54Kyellow.png Tumor classification (ICD-O-3) Kyellow.png APSR 2.0
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.33 ICD-O-3 Morphology (2015‑11‑13 14:08:46)
 Example
for use case #1: invasive breast cancer, NST, well differentiated
<value xsi:type="CD" code="8500" codeSystem="2.16.840.1.113883.6.43.1"/>
Treetree.pnghl7:performer
II0 … 1CPerforming lab

Source: PaLM TF-3: 6.3.2.20
Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)
PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3
Treetree.pnghl7:author
II0 … 1CContains 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11)PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3
Treetree.pnghl7:informant
II0 … *RInformant

Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.5
Contains 1.3.6.1.4.1.19376.1.8.1.4.6 Informant (2016‑07‑08 11:22:58)
PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3
Treetree.pnghl7:participant
II0 … *RAdditional participants

Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.6
Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry (2016‑07‑12 18:44:06)
PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3
Included1 … *R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Treetree.pnghl7:specimen
1 … *RRequired in XD-LAB when more than one specimen is documented at this level. Always required in APSR.PaLM Suppl. APSR 2.1‑3: 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:entryRelationship
1 … 1R5th digit in the morphology axis code
Contains 1.3.6.1.4.1.19376.1.3.10.9.38 ICD-O-3 Behavior (2015‑12‑03 09:11:54)
PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treetree.pnghl7:entryRelationship
0 … 1R6th digit in the morphology axis code
Contains 1.3.6.1.4.1.19376.1.3.10.9.39 ICD-O-3 Differentiation (2015‑12‑09 17:12:30)
PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSPRT
Treetree.pnghl7:entryRelationship
0 … 1Roptional grading by a scoring system, e.g. by means of the Elston-Ellis-Scoring-System in case of invasive breast cancer (ICD-O C50)
Contains 1.3.6.1.4.1.19376.1.3.10.4.4 Assessment Scales Observation for Scoring Systems (2016‑10‑06 13:12:00)
PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7:reference
0 … *RContains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3


List of all versions of this template