IHE Pathology and Laboratory Medicine (PaLM) Technical Framework Supplement - Anatomic Pathology Structured Report (APSR)

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Foreword

This is a supplement to the IHE Pathology and Laboratory Medicine Technical Framework V9.0. Each supplement undergoes a process of public comment and trial implementation before being incorporated into the volumes of the Technical Frameworks.

This supplement was published on September 28, 2018 for Trial Implementation and may be available for testing at subsequent IHE Connectathons. The supplement may be amended based on the results of testing. Following successful testing it will be incorporated into the PaLM Technical Framework. Comments are invited and may be submitted at http://www.ihe.net/PaLM_Public_Comments.

This supplement describes changes to the existing technical framework documents.

“Boxed” instructions like the sample below indicate to the Volume Editor how to integrate the relevant section(s) into the relevant Technical Framework volume.

Replace Section X.X by the following:

Where the amendment adds text, make the added text bold underline. Where the amendment removes text, make the removed text bold strikethrough. When entire new sections are added, introduce with editor’s instructions to “add new text” or similar, which for readability are not bolded or underlined.


General information about IHE can be found at https://www.ihe.net.

Information about the IHE Pathology and Laboratory Medicine domain can be found at https://www.ihe.net/ihe_domains/.

Information about the structure of IHE Technical Frameworks and Supplements can be found at https://www.ihe.net/about_ihe/ihe_process/ and https://www.ihe.net/resources/profiles/.

The current version of the IHE Technical Framework can be found at https://www.ihe.net/resources/technical_frameworks/.

Acknowledgements

The following authors mainly contributed to this document:

  • Francois Macary, PHAST, Paris
  • Dr. Gunter Haroske, Federal Association of German Pathologists, Berlin
  • Dr. Frank Oemig, Deutsche Telekom Healthcare Solutions GmbH, Bonn
  • Dr. Riki Merrick, APHL, San Francisco
  • Dr. Raj Dash, Duke University, Durham

They also acknowledge the contributions of Dr. Kai U. Heitmann, who managed the cooperation between PaLM and ART-DECOR. It was the very first time that a complete IHE Technical Framework document was developed by means of the ART-DECOR tools and Media Wiki.

Contents

Introduction to this Supplement

This supplement complements Volume 1 of the PaLM Technical Framework with the description of the Anatomic Pathology Structured Report (APSR) content profile, and Volume 3 with the structured artifacts - content modules, bindings and value sets - which specify this profile technically.

The PDF format of this specification is automatically generated from the online version, which is available to all readers on the pubswiki.ihe.net platform where it is maintained.

The structured artifacts, which represent the most part of Volume 3 content, are produced and maintained on the ART-DECOR(R) tool and platform, where they are also freely accessible to all readers. This structured part of the specification is automatically transcluded into the pubswiki.ihe.net APSR specification. Then the PDF format is generated.

Although the PDF format captures the entire specification, interested parties are most likely to prefer browsing and reading through the APSR specification directly on the two aforementioned online platforms.

Open Issues and Questions

None

Closed Issues

APSR-07 – Representing the hierarchy of specimens in an entry: This APSR supplement enables to represent the hierarchy of specimens at the CDA® [1] level 3. The operations on specimen and production of child specimens are tracked in the “Procedure Steps” section, which has a level 3 entry.

APSR-10 – Observation related to multiple specimens: For example tumor staging may require combining data from multiple specimens (e.g., a breast excision with positive margins followed by a re-excision with clear margins – in this case the tumor size may be a composite of measurements from both specimens. Another example is staging of ovarian carcinomas with multiple biopsies of pelvis, peritoneum, nodes, omentum, etc.). To accommodate these use cases, each problem organizer as well as each observation may reference any number of specimens using the <specimen> child element. Each of these references may point to a detailed description of the specimen, in the "procedure steps" section.

APSR-11 – Derivative specimens: Specimens derived from primary specimens for ancillary studies, which may be sent to a reference lab or done in another part of the same institution, are included in the scope of this profile. The results produced on a derived specimen are attached to this specimen in the report.

Volume 1 - Profiles

10 Anatomic Pathology Structured Report (APSR) Profile

This content profile describes an anatomic pathology structured report (APSR) as a digital document to be shared or exchanged between pathology laboratories and other care providers and institutions.

Anatomic pathology structured reports document the findings on specimens removed from patients for diagnostic or therapeutic reasons. This information can be used for patient care, clinical research and epidemiology. Standardizing and computerizing anatomic pathology reports is necessary to improve the quality of reporting and to facilitate the exchange and reuse of the content of these reports.

This content profile describes a digital anatomic pathology report shared in a human-readable format, which may include images, and which also contains findings and observations in a machine-readable format, to facilitate the integration of these into the database of a consumer system, and to enable the application of automated reasoning to this content.

The scope of this IHE content profile covers all fields of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as cytopathology.

Goldsmith J.D. et al. [2] is the first source of specification for this content profile. This article delineates the required, preferred, and optional elements which should be included in any report of surgical pathology.

This source is complemented by the “Cancer Checklists” produced by the College of American Pathologists [3], and by the “comptes rendus d’anatomopathologie : données minimales à renseigner pour une tumeur primitive” produced by the French society of pathology (SFP [4]) for the French cancer institute (INCa [5]), and by the German "Guideline Pathology / Neuropathology" (formerly TM-30) of the Sector Committee Pathology for the implementation of DIN EN ISO/EC 17020.

This profile has also benefited from the guidance on cancer AP reports provided by the North-American Association of Central Cancer Registries; some of the example snippets captured in the profile leverage the NAACCR Standards for Cancer Registries, Volume V, Pathology Laboratory Electronic Reporting.

10.1 APSR Actors/Transactions

This section defines the actors, transactions, and/or content modules in this profile. General definitions of actors are given in the Technical Frameworks General Introduction Appendix A published here.

Figure 10.1-1 shows the actors directly involved in the APSR Profile and the direction that the content that is exchanged.

A product implementation using this profile must group actors from this profile with actors from a workflow or transport profile to be functional. The grouping of the content module described in this profile to specific actors is described in more detail in the “Required Actor Groupings” section below.

Fig.4.1.-1.jpg

Figure 10.1-1: APSR Actor Diagram


Table 10.1-1 lists the content module(s) defined in the APSR profile. To claim support with this profile, an actor shall support all required content modules (labeled “R”) and may support optional content modules (labeled “O”).


Table 10.1-1: APSR Profile - Actors and Content Modules

Actors Content Modules Optionality Reference
Content

Creator

Anatomic Pathology Structured Report 1.3.6.1.4.1.19376.1.8.1.1.1

R PaLM TF-3: 6.3.1.2
Content

Consumer

Anatomic Pathology Structured Report 1.3.6.1.4.1.19376.1.8.1.1.1

R PaLM TF-3: 6.3.1.2

10.1.1 Actor Descriptions and Actor Profile Requirements

Most requirements are documented in Content Modules (Volume 3). This section documents any additional requirements on profile’s actors.

10.2 APSR Actor Options

Options that may be selected for each actor in this profile are listed in the table 10.2-1. These options are further detailed in PCC Technical Framework Volume 2 as indicated in the rightmost column.

Table 10.2-1 Anatomic Pathology Structured Report - Actors and Options

Actor Option Name Reference
Content

Creator

None
Content

Consumer

View Option (1)

Document Import Option (1)

Section Import Option (1)

PCC TF-2:3.1.1

PCC TF-2:3.1.2

PCC TF-2:3.1.3

Note 1: The Content Consumer shall support at least one of these options.

10.3 APSR Required Actor Groupings

An actor from this profile (Column 1) shall implement all of the required transactions and/or content modules in this profile in addition to all of the transactions required for the grouped actor (Column 2).

In some cases, required groupings are defined as at least one of an enumerated set of possible actors; this is designated by merging column one into a single cell spanning multiple potential grouped actors. Notes are used to highlight this situation.

Section 10.5 describes some optional groupings that may be of interest for security considerations and section 10.6 describes some optional groupings in other related profiles.

Table 10.3-1: Anatomic Pathology Structured Report - Required Actor Groupings

APSR Actor Actor to be grouped with Reference Content Bindings Reference
Content

Creator

ITI XDS.b Document Source

OR

ITI XDM Portable Media Creator

OR

ITI XDR Document Source

OR

ITI MHD Document Source

ITI TF-1:10


ITI TF-1:16


ITI TF-1:15


ITI TF-1:33

Content

Consumer

ITI XDS.b Document Consumer

OR

ITI XDM Portable Media Consumer

OR

ITI XDR Document Recipient

OR

ITI MHD Document Consumer

ITI TF-1:10


ITI TF-1:16


ITI TF-1:15


ITI TF-1:33

Note 1: Each actor of APSR SHALL be grouped with at least one of the ITI actors listed in its table row.

10.4 APSR Overview

10.4.1 Concepts

This content profile represents a common digital document model applicable to any structured report for surgical pathology in all fields of anatomic pathology (cancers, benign neoplasms, non-neoplastic conditions) as well as for cytopathology.

This common model is composed of a header conveying the context of care (patient, care providers, pathologists, laboratories, order, act documented …) and a body. The body organizes the human-readable content of the report in a number of sections. Each section may also provide machine-readable content in a repeatable “entry” embedded in the section. This common model defines the order of appearance, cardinalities and internal structure of each section, and of each entry embedded in each section.

Figure 10.4.1-1 shows this general model applicable to any pathology digital report.

10.4.1-1 APSR2layout.png

Figure 10.4.1-1: Common model for a digital anatomic pathology structured report

Note 1: The only section that is mandatory is the Diagnostic Conclusion section.

10.4.2 Use Cases

10.4.2.1 Use Case #1: Single Report

Anatomic pathology order fulfilled by a pathology laboratory produces a report.

10.4.2.1.1 Single Report Use Case Description

Dr. Eva Surgeon, PhD, takes a ultrasound guided core biopsy from a breast tumor from patient Eve Onewoman, born on Sept 21 1971, requests the procedure “breast core biopsy specimen - pathological examination” and sends the specimen to the anatomic pathology laboratory of the Cancer Institute. One specimen (five cores) is accessioned by the anatomic pathology laboratory under the accession number A710240008. The staff performs a macroscopic examination of the specimen; gross imaging is performed if needed. The specimen with the specimen ID A710240008_A is processed for microscopic examination and other special ancillary techniques or tissue banking if needed. During the imaging interpretation process, microscopic imaging is performed if needed. At the end of the interpretation process of the macroscopic and microscopic observations and some ancillary techniques, done by the pathologists Dr. Marcel Pathologist, PhD, and Dr. Jonas Jones, M.D., Dr. Marcel Pathologist queries the Content Creator application for the appropriate APSR template, fills the form, binds some relevant images and/or regions of interest to specific observations, validates and signs the digital report.

10.4.2.1.2 Single Report Process Flow

Flow case 1.png

10.4.2.1.3 Single Report Text Example

Macroscopic observation

A. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY):

Microscopic observation

INVASIVE ADENOCARCINOMA OF THE BREAST.
ICD-O-3-CLASSIFICATION: C50.3 M8500/33
HISTOLOGIC TYPE: DUCTAL.
NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3.
TUBULE FORMATION SCORE: 2. NUCLEAR PLEOMORPHISM SCORE: 2. MITOTIC RATE SCORE: 1.

IN-SITU CARCINOMA: EQUIVOCAL.

BREAST CANCER BIOMARKER STUDIES:
PARAFFIN BLOCK NUMBER: A1.
ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8, Percentage of positive cells = 85%, Staining Intensity score = 3).
PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED SCORE = 8).
DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.
HER2/NEU IMMUNOHISTOCHEMISTRY: AMBIGUOUS(2+) FOR OVEREXPRESSION OF HER2/NEU ONCOPROTEIN.
HER2/NEU FISH RESULT: NEGATIVE FOR AMPLIFICATION OF HER2/NEU.


Diagnostic conclusion

A. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY):

INVASIVE ADENOCARCINOMA OF THE BREAST.
ICD-O-3-CLASSIFICATION: C50.3 M8500/33
HISTOLOGIC TYPE: DUCTAL.
NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3.
TUBULE FORMATION SCORE: 2. NUCLEAR PLEOMORPHISM SCORE: 2. MITOTIC RATE SCORE: 1.

IN-SITU CARCINOMA: EQUIVOCAL.

BREAST CANCER BIOMARKER STUDIES:
PARAFFIN BLOCK NUMBER: A1.
ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8, Percentage of positive cells = 85%, Staining Intensity score = 3).
PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED SCORE = 8).
DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.
HER2/NEU IMMUNOHISTOCHEMISTRY: AMBIGUOUS(2+) FOR OVEREXPRESSION OF HER2/NEU ONCOPROTEIN.
HER2/NEU FISH RESULT: NEGATIVE FOR AMPLIFICATION OF HER2/NEU.


Procedure steps:

RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY) PARAFFIN BLOCK NUMBER: A1.:FOUR SECTIONS FOR EACH STAIN:

RIGHT BREAST FIVE CORES 8-9:00

PARAFFIN BLOCK NUMBER: A1

slide from block A1 HE stained

slide from block A1 ER Immunohistochemistry

slide from block A1 PR Immunohistochemistry

slide from block A1 EGFR (PharmDX) Immunohistochemistry

slide from block A1 HER2 Immunohistochemistry

slide block from A1 HER2 FISH

10.4.2.2 Use Case #2: Multi-step Report

Reporting includes multiple successive steps.

10.4.2.2.1 Multi-step Report Use Case Description

A surgeon removes a breast tumor from a patient, requests the procedure “breast surgical specimen - frozen sections & pathological examination”, and “breast surgical specimen - pathological examination” and sends the specimen(s) to the anatomic pathology laboratory.

Specimens are accessioned by the anatomic pathology department. The staff performs a macroscopic examination of the specimens, gross imaging is performed if needed. The specimens are processed for intraoperative observation if needed, and tissue banking if needed (e.g., for research purpose). During the imaging interpretation process of frozen sections, microscopic imaging is performed if needed. At the end of the interpretation process, the pathologist queries the Content Creator for the appropriate APSR template, fills the intraoperative observation section, binds some relevant images and/or regions of interest to specific observation(s) if needed, validates and signs (i.e., legally authenticates) the preliminary APSR.

The day after, the specimen(s) are processed for microscopic examination and other special ancillary techniques if needed. During the imaging interpretation process, microscopic imaging is performed if needed. At the end of the interpretation process, pathologist queries the Content Creator for the preliminary APSR, fills the form, binds some relevant images and/or regions of interest to specific observation(s), validates and signs (i.e., legally authenticates) the final APSR.

10.4.2.2.2 Multi-step Report Process Flow

Flow Case 2.png

10.5 APSR Security Considerations

See PaLM TF-1: Appendix A.

10.6 APSR Cross Profile Considerations

Intentionally left blank

Volume 3 – Content Modules

1 Introduction

The content of this entire section is identical to Section 1 of PaLM: TF-3.

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® [6] V3 CDA Content Modules in detail.
  • Section 7 defines the PaLM domain’s DICOM® [7] 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. Comments on the IHE initiative 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. Comments on this document can be submitted at https://www.ihe.net/PaLM_Public_Comments/.

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 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 xml instance.

Finalization of the supplement for trial implementation publication.

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 [8]
DICOM
2.16.840.1.113883.15.16 TNM 8th edition
Internationally agreed-upon standards to describe and categorize cancer stages and progression [9]
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 [9]
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 [9]
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 [9]
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.[10]
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 [11]
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 PaLM TF

The Content Modules specified in this Volume 3 of the PaLM 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 PaLM 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

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 = “60568-3”, which is the LOINC code for “Pathology Synoptic report”.

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

  • 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.

Id1.3.6.1.4.1.19376.1.8.1.1.1Effective Date2014‑05‑13 11:57:57
StatusKyellow.png DraftVersion Label2.0
NameAnatomicPathologyStructuredReportContentModuleDisplay NameAnatomic 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.
ContextPathname /
LabelPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 6 concepts
IdNameData Set
psr-data​element-32Kyellow.png Case Kyellow.png APSR 2.0
psr-data​element-50Kyellow.png Accession Number Kyellow.png APSR 2.0
psr-data​element-82Kyellow.png Placer group ID Kyellow.png APSR 2.0
psr-data​element-49Kyellow.png Order ID Kyellow.png APSR 2.0
psr-data​element-58Kyellow.png Anatomic Pathology Structured Report Kyellow.png APSR 2.0
psr-data​element-81Kyellow.png Order placer ID Kyellow.png APSR 2.0
Uses
Uses 20 templates
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.1IncludeKgreen.png Human Patient (2017)2017‑06‑07
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png Author (2.0)2016‑06‑21 14:02:11
2.16.840.1.113883.10.12.103IncludeKgreen.png CDA dataEnterer2005‑09‑07
1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png Informant (2.0)2016‑07‑08 11:22:58
2.16.840.1.113883.10.12.104IncludeKgreen.png CDA custodian2005‑09‑07
1.3.6.1.4.1.19376.1.3.3.1.4IncludeKgreen.png XD-LAB Information Recipient (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.10.2.4IncludeKgreen.png XD-LAB LegalAuthenticator (2017)2016‑07‑05
1.3.6.1.4.1.19376.1.8.1.4.3IncludeKyellow.png Content Validator2016‑07‑09 15:03:59
1.3.6.1.4.1.19376.1.3.3.1.6IncludeKgreen.png Ordering Provider (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.1IncludeKyellow.png Specimen Collector in Header2016‑06‑13 14:21:13
1.3.6.1.4.1.19376.1.3.10.2.5IncludeKyellow.png Participant Pertinent Insurance Information2017‑11‑13 16:52:30
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
2.16.840.1.113883.10.12.113IncludeKgreen.png CDA componentOf2005‑09‑07
1.3.6.1.4.1.19376.1.8.1.2.1ContainmentKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2ContainmentKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3ContainmentKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4ContainmentKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.3.10.3.1ContainmentKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.2.5ContainmentKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.2.6ContainmentKyellow.png Procedure Steps Section (2.0)2014‑05‑13 19:33:12
RelationshipSpecialization: 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"/>  <!-- Identifier of this instance of the report -->
  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_1" assigningAuthorityName="IHE PaLM Technical Committee"/>  <!-- Type of document -->
  <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"/>  <!-- common identifier to all releases of this report, extension is accession number -->
  <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', 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' 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' 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"/>      <!-- Status of the report -->
      <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' 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>
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
 
Target.png
psr-data​element-58Kyellow.png Anatomic Pathology Structured Report Kyellow.png APSR 2.0
Treetree.png@classCode
cs1 … 1FDOCCLIN
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1MThis 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 2.1‑3: 6.3.1.1 APSR document content module
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.1.1
Treetree.pnghl7:realmCode
CS (extensible)1 … 1MThis 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 2.1‑3: 6.3.1.1 APSR document content module
Treetree.pnghl7:typeId
II1 … 1MThis 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 2.1‑3: 6.3.1.1 APSR document content module
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.1.3
Treeblank.pngTreetree.png@extension
st1 … 1FPOCD_HD000040
Treetree.pnghl7:id
II1 … 1MClinicalDocument/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 2.1‑3: 6.3.1.1 APSR document content module
 
Target.png
psr-data​element-32Kyellow.png Case Kyellow.png APSR 2.0
Treeblank.pngTreetree.png@root
uid1 … 1RHere the OID for PAT exemplary instances, in practice the OID of the AP-LIS
Treeblank.pngTreetree.png@extension
st1 … 1RHere a hypothetical document ID, most often derived from the accession number
 ConstraintA 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"/>
Treetree.pnghl7:code
CE (required)1 … 1MClinicalDocument/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 2.1‑3: 6.3.1.1 APSR document content module
Treeblank.pngTreetree.png@code
CONF1 … 1F60568-3
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1FPathology Synoptic report
Treetree.pnghl7:title
ST1 … 1MThe APSR <title> SHALL be present. It is the local translation of the code@displayName.
PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
 Example
Report title from use case #1
<title>ANATOMIC PATHOLOGY REPORT - BREAST BIOPSY</title>
Treetree.pnghl7:effectiveTime
TS1 … 1MClinicalDocument/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 2.1‑3: 6.3.1.1 APSR document content module
Treetree.pnghl7:confidentialityCode
CE (required)1 … 1MClinicalDocument/confidentialityCode SHALL be present in accordance with the HL7 CDA R2 standard.
PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR 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)
Treetree.pnghl7:language​Code
CS (required)1 … 1MClinicalDocument/languageCode SHALL be present in accordance with the HL7 CDA R2 standard.
PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR 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)
Treetree.pnghl7:setId
II1 … 1MClinicalDocument/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 2.1‑3: 6.3.1.1 APSR document content module
Treeblank.pngTreetree.png@root
uid1 … 1R
Treeblank.pngTreetree.png@extension
st1 … 1R
 
Target.png
psr-data​element-50Kyellow.png Accession Number Kyellow.png APSR 2.0
 ConstraintA 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"/>
Treetree.pnghl7:versionNumber
INT0 … 1RClinicalDocument/versionNumber MAY be present. As requested by the CDA standard, it is an integer value used as versioning.
PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
Treeblank.pngTreetree.png@value
int1 … 1R
 ConstraintA 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"/>
Included1 … 1M 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.
    Treetree.pnghl7:recordTarget
    1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreetree.pnghl7:patientRole
    1 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    II1 … *RPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    AD1 … *All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    TEL1 … *All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:patient
    1 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    II0 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    PN1 … *PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:administrative​Gender​Code
    CE1 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:birthTime
    TS1 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Included1 … *M from 1.3.6.1.4.1.19376.1.8.1.4.2 Author (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
    Treetree.pnghl7:author
    1 … *MPaLM 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
    Included0 … *R from 2.16.840.1.113883.10.12.103 CDA dataEnterer (2005‑09‑07)
    Transcriptionist
    Treetree.pnghl7:dataEnterer
    0 … *RPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreetree.png@typeCode
    0 … 1FENT
    Treeblank.pngTreetree.png@context​Control​Code
    0 … 1FOP
    Treeblank.pngTreetree.pnghl7:time
    TS0 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreetree.pnghl7:assignedEntity
    1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
     
    Target.png
    psr-data​element-76Kyellow.png Secretary Kyellow.png APSR 2.0
    Treetree.pnghl7:informant
    0 … *RZero 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. In an anatomic pathology structured report informants are only healthcare professionals. There is no point for such a report to mention persons related to the patient (next of kin, employer, guarantor, …).

    Source: PaLM 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: 6.3.1.1 APSR document content module
    Included1 … 1M 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.
    Treetree.pnghl7:custodian
    1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
     
    Target.png
    psr-data​element-38Kyellow.png Custodian Kyellow.png APSR 2.0
    Treeblank.pngTreetree.png@typeCode
    0 … 1FCST
    Treeblank.pngTreetree.pnghl7:assignedCustodian
    1 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    0 … 1FASSIGNED
    Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Custodian​Organization
    1 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    II1 … *MPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    ON0 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    TEL0 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    AD0 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Included0 … *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
    Treetree.pnghl7:information​Recipient
    0 … *RPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreetree.pnghl7:templateId
    II1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.png@root
    uid1 … 1F1.3.6.1.4.1.19376.1.3.3.1.4
    Treeblank.pngTreetree.pnghl7:intended​Recipient
    1 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    II0 … *RPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    AD1 … *PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    TEL1 … *PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:information​Recipient
    0 … 1Contains 1.3.6.1.4.1.19376.1.3.10.9.18 PlayingEntity or person with Name (DYNAMIC)PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:received​Organization
    0 … 1Contains 1.3.6.1.4.1.19376.1.3.10.9.13 Organization with Name, Addr, Telecom (DYNAMIC)PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Included1 … 1M 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

    Treetree.pnghl7:legalAuthenticator
    1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreetree.pnghl7:time
    TS1 … 1R

    The sub-element time carries the date&time this legal authentication took place.

    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreetree.pnghl7:signatureCode
    CS1 … 1R

    The sub-element signatureCode carries the “signed” (S) status

    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.png@code
    CONF0 … 1FS
    Treeblank.pngTreetree.pnghl7:assignedEntity
    1 … 1R

    All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.

    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    AD1 … *R

    Constrained by this specification to require the presence of name, addr and telecom.

    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    TEL1 … *R

    Constrained by this specification to require the presence of name, addr and telecom.

    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7: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 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7: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 2.1‑3: 6.3.1.1 APSR document content module
    Included0 … *R from 1.3.6.1.4.1.19376.1.8.1.4.3 Content Validator (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 

    Treetree.pnghl7:authenticator
    0 … *RPaLM Suppl. APSR 2.1‑3: 6.3.2.2 Content validator
     
    Target.png
    psr-data​element-4Kyellow.png Pathologist Kyellow.png APSR 2.0
    Treeblank.pngTreetree.png@typeCode
    cs1 … 1FAUTHEN
    Treeblank.pngTreetree.pnghl7:templateId
    1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.2.2 Content validator
    Treeblank.pngTreeblank.pngTreetree.png@root
    uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.3
    Treeblank.pngTreetree.pnghl7:time
    TS1 … 1RTime of validationPaLM Suppl. APSR 2.1‑3: 6.3.2.2 Content validator
    Treeblank.pngTreetree.pnghl7:assignedEntity
    0 … 1CAssignedPerson 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 2.1‑3: 6.3.2.2 Content validator
    Included1 … 1R 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
    Treetree.pnghl7:participant
    1 … 1RReferral Ordering PhysicianPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
     
    Target.png
    psr-data​element-48Kyellow.png Ordering Physician Kyellow.png APSR 2.0
    psr-data​element-78Kyellow.png Clinician Kyellow.png APSR 2.0
    Treeblank.pngTreetree.png@typeCode
    cs1 … 1FREF
    Treeblank.pngTreetree.pnghl7:templateId
    II1 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.png@root
    uid1 … 1F1.3.6.1.4.1.19376.1.3.3.1.6
    Treeblank.pngTreetree.pnghl7:time
    IVL_TS1 … 1RThis element represents the date and time the order was placed. Time MAY be present.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreetree.pnghl7:associated​Entity
    1 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    AD1 … *RThe address of this person (referral ordering physician) SHALL be present.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    TEL1 … *RThe telecom of this person (referral ordering physician) SHALL be present.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
     Schematron assertroleKred.png error 
     testnot(hl7:assigned​Person) or hl7:assigned​Person/hl7:name 
     MessageThe <name> sub-element SHALL be present when <assignedPerson> present. 
    Treeblank.pngTreeblank.pngTreetree.pnghl7:associated​Person
    0 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:scoping​Organization
    0 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Included0 … *R from 1.3.6.1.4.1.19376.1.8.1.4.1 Specimen Collector in Header (2016‑06‑13 14:21:13)
    Specimen Collector other than ordering physician. 

    Source: PAT TF-3: 6.2.6.1


    Treetree.pnghl7:participant
    0 … *RThe 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 2.1‑3:6.3.2.1 Specimen collector
     
    Target.png
    psr-data​element-78Kyellow.png Clinician Kyellow.png APSR 2.0
    psr-data​element-52Kyellow.png Specimen Collector Kyellow.png APSR 2.0
    Treeblank.pngTreetree.png@typeCode
    cs1 … 1FDIST
    Treeblank.pngTreetree.pnghl7:templateID
    II1 … 1MPaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.png@root
    uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.1
    Treeblank.pngTreetree.pnghl7:time
    IVL_TS1 … 1MSpecimen 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 2.1‑3:6.3.2.1 Specimen collector
    Treeblank.pngTreetree.pnghl7:associated​Entity
    0 … 1RAt least one of the two elements associatedPerson and scopingOrganization must be present. Both may be present. 

    PaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    cs1 … 1FPROV
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    II1 … *RPaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    AD1 … *RPaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    TEL1 … *RPaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.pnghl7:associated​Person
    0 … *CPerson 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 2.1‑3:6.3.2.1 Specimen collector
    Treeblank.pngTreeblank.pngTreetree.pnghl7:scoping​Organization
    0 … 1COrganization 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 2.1‑3:6.3.2.1 Specimen collector
    Included0 … 1R from 1.3.6.1.4.1.19376.1.3.10.2.5 Participant Pertinent Insurance Information (2017‑11‑13 16:52:30)
    Key insurance information of the patient.
    Treetree.pnghl7:participant
    0 … 1RInsurance information of the patient in context for reporting to cancer registries (in Germany)PaLM Suppl. 2.1‑3:6.3.2.3
    Treeblank.pngTreetree.png@typeCode
    cs1 … 1FHLD
    Treeblank.pngTreetree.pnghl7:templateId
    II1 … *MPaLM Suppl. 2.1‑3:6.3.2.3
    Treeblank.pngTreeblank.pngTreetree.png@root
    uid1 … 1F1.3.6.1.4.1.19376.1.3.10.2.5
    Treeblank.pngTreetree.pnghl7:time
    IVL_TS0 … 1Rtime shows the end of the current insurance period, e.g. end of the quartalPaLM Suppl. 2.1‑3:6.3.2.3
     Example<time>
      <high value="20171231"/></time>
    Treeblank.pngTreetree.pnghl7:associated​Entity
    1 … 1MData of the insured personPaLM Suppl. 2.1‑3:6.3.2.3
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    cs1 … 1FPOLHOLD
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    II0 … *RID(s) of the insured person (patient), e.g. ID of the insured, ID of the health card, etc.PaLM Suppl. 2.1‑3:6.3.2.3
    Treeblank.pngTreeblank.pngTreetree.pnghl7:code
    CE0 … 1Rstatus of the insured personPaLM Suppl. 2.1‑3:6.3.2.3
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    CONF0 … 1F2.16.840.1.113883.5.111 (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>
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:translation
    CV0 … 1Rfurther 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. 2.1‑3:6.3.2.3
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    AD0 … 1RPaLM Suppl. 2.1‑3:6.3.2.3
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    TEL0 … *RPaLM Suppl. 2.1‑3:6.3.2.3
    Treeblank.pngTreeblank.pngTreetree.pnghl7:associated​Person
    0 … 1RData 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. 2.1‑3:6.3.2.3
    Treeblank.pngTreeblank.pngTreetree.pnghl7:scoping​Organization
    1 … 1RData 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. 2.1‑3:6.3.2.3
    Treetree.pnghl7:inFulfillmentOf
    0 … 1RThe 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 2.1‑3: 6.3.1.1 APSR document content module
     
    Target.png
    psr-data​element-49Kyellow.png Order ID Kyellow.png APSR 2.0
    Treeblank.pngTreetree.png@typeCode
    cs1 … 1FFLFS
    Treeblank.pngTreetree.pnghl7:order
    1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    cs1 … 1FACT
    Treeblank.pngTreeblank.pngTreetree.png@moodCode
    cs1 … 1FRQO
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    II1 … *RPlacer order group ID or Placer order ID.
    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
     
    Target.png
    psr-data​element-82Kyellow.png Placer group ID Kyellow.png APSR 2.0
    psr-data​element-81Kyellow.png Order placer ID Kyellow.png APSR 2.0
    Treetree.pnghl7:documentationOf
    1 … 1MDocumented act.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreetree.png@typeCode
    cs1 … 1FDOC
    Treeblank.pngTreetree.pnghl7:serviceEvent
    1 … 1MThe 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 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    cs1 … 1R
    Treeblank.pngTreeblank.pngTreetree.png@moodCode
    cs1 … 1R
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    II1 … *MID of the Act, i.e. Accession numberPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
     
    Target.png
    psr-data​element-50Kyellow.png Accession Number Kyellow.png APSR 2.0
    psr-data​element-82Kyellow.png Placer group ID Kyellow.png APSR 2.0
    psr-data​element-49Kyellow.png Order ID Kyellow.png APSR 2.0
    Treeblank.pngTreeblank.pngTreetree.pnghl7:code
    CE (extensible)0 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR 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)"
    Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    IVL_TS0 … 1RUse of sub element documentationOf/serviceEvent/effectiveTime to document the time boundaries of events in the document is appropriate.
    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnglab:statusCode
    CS (required)0 … 1RThe 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 2.1‑3: 6.3.1.1 APSR document content module
     ConstraintThe 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 assertroleKred.png error 
     testhl7:serviceEvent/lab:statusCode[@code='completed'] 
     MessageStatus code of all Content Modules SHALL be "complete" or "aborted" 
    Treeblank.pngTreeblank.pngTreetree.pnghl7:performer
    0 … *RContains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.png where [hl7:assignedEntity]
    Treetree.pnghl7:relatedDocument
    0 … 1R

    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 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreetree.png@typeCode
    cs1 … 1FRPLC
     relatedDocument@typeCode attribute SHALL be valued "RPLC"
    Treeblank.pngTreetree.pnghl7:parentDocument
    ANY1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    II1 … 1MSHALL be equal to ClinicalDocument/ id of the replaced document.
    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:setId
    II1 … 1MSHALL have the same value in the new report as in the replaced report.
    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:versionNumber
    INT0 … 1RSHALL have the same value as in the replaced report (when provided there).
    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Included0 … 1R 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.

    Treetree.pnghl7:componentOf
    0 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreetree.png@typeCode
    0 … 1FCOMP
    Treeblank.pngTreetree.pnghl7:encompassing​Encounter
    1 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    0 … 1FENC
    Treeblank.pngTreeblank.pngTreetree.png@moodCode
    0 … 1FEVN
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    II0 … *PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:code
    CE0 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
     CONF
    The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC)
    Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    IVL_TS1 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:discharge​Disposition​Code
    CE0 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
     CONF
    shall be drawn from concept domain "EncounterDischargeDisposition"
    Treeblank.pngTreeblank.pngTreetree.pnghl7:responsible​Party
    0 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    0 … 1FRESP
    Treeblank.pngTreeblank.pngTreetree.pnghl7:encounterParticipant
    0 … *PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    cs1 … 1R
     CONF
    The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:time
    IVL_TS0 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assignedEntity
    1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.pnghl7:location
    0 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    0 … 1FLOC
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:health​Care​Facility
    1 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    0 … 1FSDLOC
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    II0 … *PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    CE0 … 1PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
     CONF
    The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:location
    0 … 1Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC)PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:service​Provider​Organization
    0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treetree.pnghl7:component
    1 … 1RBody of the CDA Clinical documentPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreetree.png@typeCode
    cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    bl1 … 1Ftrue
    Treeblank.pngTreetree.pnghl7:structuredBody
    1 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    cs1 … 1FDOCBODY
    Treeblank.pngTreeblank.pngTreetree.png@moodCode
    cs1 … 1FEVN
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    0 … 1RThe 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 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '22636-5' and @codeSystem = '2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    0 … 1RThe 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). 

    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 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '83321-0' and @codeSystem = '2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    0 … 1RThe 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 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '22634-0' and @codeSystem = '2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    0 … 1RThe 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 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '22635-7' and @codeSystem = '2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    0 … 1RThe 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 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = 'xxxxx-x' and @codeSystem = '2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    1 … 1MThe 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 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '22637-3' and @codeSystem = '2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    bl1 … 1Ftrue
    Treeblank.pngTreeblank.pngTreetree.pnghl7:component
    0 … 1RThe 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 2.1‑3: 6.3.1.1 APSR document content module
    Treeblank.pngTreeblank.pngTreeblank.png where [hl7:section [hl7:code [(@code = '46059-2' and @codeSystem = '2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
    cs1 … 1FCOMP
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
    bl1 … 1Ftrue
    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 describes the high-level view of the structure of the Problem Organizer Entry, which is common to the first six CDA APSR 2.0 sections.


    6.2.1.3-1-FO ProblemOrganizerEntry.png

    Figure 6.3.1.2.2-1 Structure of machine-readable content for the first 6 sections of APSR 2.0 CDA R2 Document Template

    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: 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.

    6.2.1.3-2-FO ProcedureStep.png

    Figure 6.3.1.2.2-2 Structure of machine-readable content for the Procedure Step section of APSR 2.0 CDA R2 Document Template

    6.3.2 CDA Header Content Modules

    6.3.2.1 <Specimen Collector in Header> - Header Content Module – 1.3.6.1.4.1.19376.1.8.1.4.1

    6.3.2.1.1 Definition and purpose

    This Content Module is usable only in the CDA header.

    This Content Module is used only in the situation where the specimen was not collected by the ordering physician. (See use cases in volume 1)

    6.3.2.1.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.4.1Effective Date2016‑06‑13 14:21:13
    StatusKyellow.png DraftVersion Label
    NameCDAParticipantSpecimenCollectorDisplay NameSpecimen Collector in Header
    Description
    Template CDA participant (prototype, directly derived from POCD_RM000040 MIF)

    This Content Module is usable only in the CDA header. 

    This Content Module is used only in the situation where the specimen was not collected by the ordering physician.



    LabelPaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    ClassificationCDA Header Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Associated with
    Associated with 2 concepts
    IdNameData Set
    psr-data​element-78Kyellow.png Clinician Kyellow.png APSR 2.0
    psr-data​element-52Kyellow.png Specimen Collector Kyellow.png APSR 2.0
    Uses
    Uses 2 templates
    Uses as NameVersion
    2.16.840.1.113883.10.12.152ContainmentKgreen.png CDA Person2005‑09‑07
    2.16.840.1.113883.10.12.151ContainmentKgreen.png CDA Organization2005‑09‑07
    RelationshipSpecialization: template 2.16.840.1.113883.10.12.108 (2005‑09‑07)
    Example
    generated example
    <participant typeCode="DIST" contextControlCode="OP">
      <templateID root="1.3.6.1.4.1.19376.1.8.1.4.1"/>  <time>
        <low value="20170127121035"/>  </time>
      <associatedEntity classCode="PROV">
        <id root="1.2.3.999" extension="--example only--"/>    <code code="--code--" codeSystem="2.16.840.1.113883.5.111"/>    <addr>addr</addr>    <telecom/>    <associatedPerson>
          <!-- template 2.16.840.1.113883.10.12.152 'CDA Person' (dynamic) -->
        </associatedPerson>
        <scopingOrganization>
          <!-- template 2.16.840.1.113883.10.12.151 'CDA Organization' (dynamic) -->
        </scopingOrganization>
      </associatedEntity>
    </participant>
    ItemDTCardConfDescriptionLabel
    hl7:participant
    0 … *RThe 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 2.1‑3:6.3.2.1 Specimen collector
     
    Target.png
    psr-data​element-78Kyellow.png Clinician Kyellow.png APSR 2.0
    psr-data​element-52Kyellow.png Specimen Collector Kyellow.png APSR 2.0
    Treetree.png@typeCode
    cs1 … 1FDIST
    Treetree.pnghl7:templateID
    II1 … 1MPaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    Treeblank.pngTreetree.png@root
    uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.1
    Treetree.pnghl7:time
    IVL_TS1 … 1MSpecimen 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 2.1‑3:6.3.2.1 Specimen collector
    Treetree.pnghl7:associated​Entity
    0 … 1RAt least one of the two elements associatedPerson and scopingOrganization must be present. Both may be present. 

    PaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    Treeblank.pngTreetree.png@classCode
    cs1 … 1FPROV
    Treeblank.pngTreetree.pnghl7:id
    II1 … *RPaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    Treeblank.pngTreetree.pnghl7:addr
    AD1 … *RPaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    Treeblank.pngTreetree.pnghl7:telecom
    TEL1 … *RPaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    Treeblank.pngTreetree.pnghl7:associated​Person
    0 … *CPerson 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 2.1‑3:6.3.2.1 Specimen collector
    Treeblank.pngTreetree.pnghl7:scoping​Organization
    0 … 1COrganization 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 2.1‑3:6.3.2.1 Specimen collector

    6.3.2.2 <Content Validator> - Header Content Module – 1.3.6.1.4.1.19376.1.8.1.4.3

    6.3.2.2.1 Definition and purpose

    This Content Module is usable only in the CDA header.

    It 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.

    6.3.2.2.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.4.3Effective Date2016‑07‑09 15:03:59
    StatusKyellow.png DraftVersion Label
    NameCDAauthenticatorIHEDisplay NameContent Validator
    Description
    Template CDA authenticator (prototype, directly derived from POCD_RM000040 MIF)

    This Content Module is usable only in the CDA header. 

    It 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.


    LabelPaLM Suppl. APSR 2.1‑3: 6.3.2.2 Content validator
    ClassificationCDA Header Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Associated with
    Associated with 1 concept
    IdNameData Set
    psr-data​element-4Kyellow.png Pathologist Kyellow.png APSR 2.0
    Uses
    Uses 1 template
    Uses as NameVersion
    2.16.840.1.113883.10.12.153ContainmentKgreen.png CDA AssignedEntity2005‑09‑07
    RelationshipAdaptation: template 2.16.840.1.113883.10.12.107 (2005‑09‑07)
    Example
    example from use case #1
    <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>
    ItemDTCardConfDescriptionLabel
    hl7:authenticator
    0 … *RPaLM Suppl. APSR 2.1‑3: 6.3.2.2 Content validator
     
    Target.png
    psr-data​element-4Kyellow.png Pathologist Kyellow.png APSR 2.0
    Treetree.png@typeCode
    cs1 … 1FAUTHEN
    Treetree.pnghl7:templateId
    1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.2.2 Content validator
    Treeblank.pngTreetree.png@root
    uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.3
    Treetree.pnghl7:time
    TS1 … 1RTime of validationPaLM Suppl. APSR 2.1‑3: 6.3.2.2 Content validator
    Treetree.pnghl7:assignedEntity
    0 … 1CAssignedPerson 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 2.1‑3: 6.3.2.2 Content validator


    6.3.2.3 <Participant Pertinent Insurance Information> - Header Content Module - 1.3.6.1.4.1.19376.1.3.10.2.5

    6.3.2.3.1 Definition and purpose

    This participant is carrying key information of the insurance status of the patient, as it may be requested for example, by cancer registries. It is used in a header only. It is not intended to provide the whole information about payment details.

    6.3.2.3.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.3.10.2.5Effective Date2017‑11‑13 16:52:30
    Other versions this id:
    • Kblank.png CDAparticipantPertinentInsuranceInformation as of 2017‑11‑13 15:51:57
    • Kblank.png CDAparticipantPertinentInsuranceInformation as of 2017‑11‑13 15:46:20
    StatusKyellow.png DraftVersion Label
    NameCDAparticipantPertinentInsuranceInformationDisplay NameParticipant Pertinent Insurance Information
    Description
    Template CDA participant (prototype, directly derived from POCD_RM000040 MIF)

    Header element template for pertinent insurance information of the patient, not intended to provide the whole information about payment details but only basic insurance IDs and address details
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.2.5
    LabelPaLM Suppl. 2.1‑3:6.3.2.3
    ClassificationCDA Header Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Uses
    Uses 2 templates
    Uses as NameVersion
    2.16.840.1.113883.10.12.152ContainmentKgreen.png CDA Person2005‑09‑07
    2.16.840.1.113883.10.12.151ContainmentKgreen.png CDA Organization2005‑09‑07
    RelationshipAdaptation: template 2.16.840.1.113883.10.12.108 (2005‑09‑07)
    Equivalent: template 1.2.276.0.76.3.1.135.8.10.8 (2016‑02‑19)
    Example
    generated example
    <participant typeCode="HLD" contextControlCode="OP">
      <templateID root="1.3.6.1.4.1.19376.1.3.10.2.5"/>  <time>
        <high value="20171231"/>  </time>
      <associatedEntity>
        <id root="1.2.3.999" extension="--example only--"/>    <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>
        <addr/>    <telecom value="tel:+1-12345678"/>    <associatedPerson>
          <!-- template 2.16.840.1.113883.10.12.152 'CDA Person' (2005-09-07T00:00:00) -->
        </associatedPerson>
        <scopingOrganization>
          <!-- template 2.16.840.1.113883.10.12.151 'CDA Organization' (2005-09-07T00:00:00) -->
        </scopingOrganization>
      </associatedEntity>
    </participant>
    ItemDTCardConfDescriptionLabel
    hl7:participant
    0 … *RInsurance information of the patient in context for reporting to cancer registries (in Germany)PaLM Suppl. 2.1‑3:6.3.2.3
    Treetree.png@typeCode
    cs1 … 1FHLD
    Treetree.pnghl7:templateId
    II1 … *MPaLM Suppl. 2.1‑3:6.3.2.3
    Treeblank.pngTreetree.png@root
    uid1 … 1F1.3.6.1.4.1.19376.1.3.10.2.5
    Treetree.pnghl7:time
    IVL_TS0 … 1Rtime shows the end of the current insurance period, e.g. end of the quartalPaLM Suppl. 2.1‑3:6.3.2.3
     Example<time>
      <high value="20171231"/></time>
    Treetree.pnghl7:associated​Entity
    1 … 1MData of the insured personPaLM Suppl. 2.1‑3:6.3.2.3
    Treeblank.pngTreetree.png@classCode
    cs1 … 1FPOLHOLD
    Treeblank.pngTreetree.pnghl7:id
    II0 … *RID(s) of the insured person (patient), e.g. ID of the insured, ID of the health card, etc.PaLM Suppl. 2.1‑3:6.3.2.3
    Treeblank.pngTreetree.pnghl7:code
    CE0 … 1Rstatus of the insured personPaLM Suppl. 2.1‑3:6.3.2.3
    Treeblank.pngTreeblank.pngTreetree.png@codeSystem
    CONF0 … 1F2.16.840.1.113883.5.111 (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>
    Treeblank.pngTreeblank.pngTreetree.pnghl7:translation
    CV0 … 1Rfurther 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. 2.1‑3:6.3.2.3
    Treeblank.pngTreetree.pnghl7:addr
    AD0 … 1RPaLM Suppl. 2.1‑3:6.3.2.3
    Treeblank.pngTreetree.pnghl7:telecom
    TEL0 … *RPaLM Suppl. 2.1‑3:6.3.2.3
    Treeblank.pngTreetree.pnghl7:associated​Person
    0 … 1RData 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. 2.1‑3:6.3.2.3
    Treeblank.pngTreetree.pnghl7:scoping​Organization
    1 … 1RData 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. 2.1‑3:6.3.2.3

    6.3.3 CDA Section Content Modules

    6.3.3.1 <Clinical Information> - Section Content Module - 1.3.6.1.4.1.19376.1.8.1.2.1

    6.3.3.1.1 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 entry for this section is the Problem Organizer Entry module.

    6.3.3.1.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.2.1Effective Date2014‑05‑13 14:38:08
    StatusKyellow.png DraftVersion Label2.0
    NameClinicalInformationSectionDisplay NameClinical 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).
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.1
    LabelPaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
    ClassificationCDA Section Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Associated with
    Associated with 4 concepts
    IdNameData Set
    psr-data​element-43Kyellow.png Clinical Problem Kyellow.png APSR 2.0
    psr-data​element-40Kyellow.png Clinical Information Kyellow.png APSR 2.0
    psr-data​element-42Kyellow.png History of Present Illness Kyellow.png APSR 2.0
    psr-data​element-41Kyellow.png Reason for Referral Kyellow.png APSR 2.0
    Uses
    Uses 5 templates
    Uses as NameVersion
    1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
    1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png Author (2.0)2016‑06‑21 14:02:11
    1.3.6.1.4.1.19376.1.5.3.1.3.1ContainmentKgreen.png IHE Reason for Referral Section (2014)2016‑09‑26 07:58:18
    1.3.6.1.4.1.19376.1.5.3.1.3.4ContainmentKgreen.png IHE History of Present Illness Section (2014)2013‑01‑31
    1.3.6.1.4.1.19376.1.5.3.1.3.6ContainmentKgreen.png IHE Active Problems Section (2014)2015‑10‑05 16:02:07
    RelationshipSpecialization: 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>
    ItemDTCardConfDescriptionLabel
    hl7:section
    0 … 1RPaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
     
    Target.png
    psr-data​element-40Kyellow.png Clinical Information 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="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.

    Treetree.pnghl7:templateId
    II1 … 1RPaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
    Treeblank.pngTreetree.png@root
    uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.1
    Treetree.pnghl7:code
    CE1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
    Treeblank.pngTreetree.png@code
    CONF1 … 1F22636-5
    Treeblank.pngTreetree.png@codeSystem
    1 … 1F2.16.840.1.113883.6.1 (LOINC)
    Treeblank.pngTreetree.png@codeSystemName
    1 … 1FLOINC
    Treeblank.pngTreetree.png@displayName
    1 … 1FPathology report relevant history
    Treetree.pnghl7:title
    ST1 … 1RThe Clinical Information Section<title> SHALL be present. It is the local translation of the code@displayName 
    PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
     Example<title>CLINICAL INFORMATION</title>
    Treetree.pnghl7:text
    SD.TEXT1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
     Example<text> Tissue submitted: left breast biopsy and apical axillary tissue </text>
    Treetree.pnghl7:language​Code
    CS0 … 1PaLM Suppl. 2.1‑3: 6.3.3.1 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)
    Treetree.pnghl7:entry
    ANY0 … *RProblem organizer
    Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (2015‑08‑13 10:24:55)
    PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
    Treeblank.png where [hl7:organizer]
    Treeblank.pngTreetree.png@typeCode
    cs0 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    bl0 … 1Ftrue
    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:component
    0 … 1Subsection

    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. 2.1‑3: 6.3.3.1 Clinical information section
    Treeblank.png where [hl7:section [hl7:code [(@code = '42349-1' and @codeSystem = '2.16.840.1.113883.6.1')]]]
     
    Target.png
    psr-data​element-41Kyellow.png Reason for Referral Kyellow.png APSR 2.0
    Treetree.pnghl7:component
    0 … 1Subsection


    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. 2.1‑3: 6.3.3.1 Clinical information section
    Treeblank.png where [hl7:section [hl7:code [(@code = '10164-2' and @codeSystem = '2.16.840.1.113883.6.1')]]]
     
    Target.png
    psr-data​element-42Kyellow.png History of Present Illness Kyellow.png APSR 2.0
    Treetree.pnghl7:component
    0 … 1Subsection

    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. 2.1‑3: 6.3.3.1 Clinical information section
    Treeblank.png where [hl7:section [hl7:code [(@code = '11450-4' and @codeSystem = '2.16.840.1.113883.6.1')]]]
     
    Target.png
    psr-data​element-43Kyellow.png Clinical Problem Kyellow.png APSR 2.0

    6.3.3.2 <Intraoperative Observation>- Section Content Module - 1.3.6.1.4.1.19376.1.8.1.2.2

    6.3.3.2.1 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.

    6.3.3.2.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.2.2Effective Date2014‑05‑13 19:29:16
    StatusKyellow.png DraftVersion Label2.0
    NameIntraoperativeObservationSectionDisplay NameIntraoperative 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).
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.2
    LabelPaLM Suppl. 2.1‑3: 6.3.3.2 Intraoperative observation section
    ClassificationCDA Section Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Associated with
    Associated with 2 concepts
    IdNameData Set
    psr-data​element-64Kyellow.png intraoperative observation text Kyellow.png APSR 2.0
    psr-data​element-44Kyellow.png Intraoperative 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
    RelationshipSpecialization: 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>
    ItemDTCardConfDescriptionLabel
    hl7:section
    0 … 1RPaLM Suppl. 2.1‑3: 6.3.3.2 Intraoperative observation section
     
    Target.png
    psr-data​element-44Kyellow.png Intraoperative observation Kyellow.png APSR 2.0
    Treetree.png@classCode
    cs1 … 1FDOCSECT
    Treetree.png@moodCode
    cs1 … 1FEVN
     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.

    Treetree.pnghl7:templateId
    II1 … 1RPaLM Suppl. 2.1‑3: 6.3.3.2 Intraoperative observation section
    Treeblank.pngTreetree.png@root
    uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.2
    Treetree.pnghl7:code
    CE1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.2 Intraoperative observation section
    Treeblank.pngTreetree.png@code
    CONF1 … 1F83321-0
    Treeblank.pngTreetree.png@codeSystem
    1 … 1F2.16.840.1.113883.6.1 (LOINC)
    Treeblank.pngTreetree.png@codeSystemName
    1 … 1FLOINC
    Treeblank.pngTreetree.png@displayName
    1 … 1FPathology report intraoperative observation in Specimen Document
    Treetree.pnghl7:title
    ST1 … 1RThe Intraoperative Observation Section<title> SHALL be present. It is the local translation of the code@displayName 
    PaLM Suppl. 2.1‑3: 6.3.3.2 Intraoperative observation section
    Treetree.pnghl7:text
    SD.TEXT1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.2 Intraoperative observation section
     
    Target.png
    psr-data​element-64Kyellow.png intraoperative observation text Kyellow.png APSR 2.0
     Example
    Intraoperative observation
    <text>Frozen section diagnosis of infiltrating duct carcinoma, left breast</text>
    Treetree.pnghl7:language​Code
    CS0 … 1PaLM Suppl. 2.1‑3: 6.3.3.2 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)
    Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11)
    Author
    Source: PaLM Suppl. APSR 2.0-3: 6.2.6.2
    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: 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. 2.1‑3: 6.3.3.2 Intraoperative observation section
    Treeblank.png where [hl7:organizer]
    Treeblank.pngTreetree.png@typeCode
    cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    bl0 … 1Ftrue

    6.3.3.3 <Macroscopic Observation> - Section Content Module - 1.3.6.1.4.1.19376.1.8.1.2.3

    6.3.3.3.1 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.

    6.3.3.3.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.2.3Effective Date2014‑05‑13 11:57:09
    StatusKyellow.png DraftVersion Label2.0
    NameMacroscopySectionDisplay NameMacroscopic 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.
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.3
    LabelPaLM Suppl. 2.1‑3: 6.3.3.3 Macroscopic observation section
    ClassificationCDA Section Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Associated with
    Associated with 2 concepts
    IdNameData Set
    psr-data​element-31Kyellow.png macroscopic observation text Kyellow.png APSR 2.0
    psr-data​element-30Kyellow.png Macroscopic 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
    RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
    Example
    example from use case #1
    <section classCode="DOCSECT">
      <templateId root="1.3.6.1.4.1.19376.1.8.1.2.3"/>  <code code="22634-0" displayName="Pathology report gross observation" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <title>MACROSCOPIC OBSERVATION SECTION</title>  <text>
        <paragraph> A. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)</paragraph>  </text>
    </section>
    ItemDTCardConfDescriptionLabel
    hl7:section
    0 … 1RPaLM Suppl. 2.1‑3: 6.3.3.3 Macroscopic observation section
     
    Target.png
    psr-data​element-30Kyellow.png Macroscopic observation Kyellow.png APSR 2.0
     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.

    Treetree.pnghl7:templateId
    II1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.3 Macroscopic observation section
    Treeblank.pngTreetree.png@root
    uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.3
    Treetree.pnghl7:code
    CE1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.3 Macroscopic observation section
    Treeblank.pngTreetree.png@code
    CONF1 … 1F22634-0
    Treeblank.pngTreetree.png@codeSystem
    1 … 1F2.16.840.1.113883.6.1 (LOINC)
    Treeblank.pngTreetree.png@codeSystemName
    1 … 1FLOINC
    Treeblank.pngTreetree.png@displayName
    1 … 1FPathology report gross observation
    Treetree.pnghl7:title
    ST1 … 1RThe Macroscopic Observation Section<title> SHALL be present. It is the local translation of the code@displayName 
    PaLM Suppl. 2.1‑3: 6.3.3.3 Macroscopic observation section
     Example<title>Macroscopic Observation</title>
    Treetree.pnghl7:text
    SD.TEXT1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.3 Macroscopic observation section
     
    Target.png
    psr-data​element-31Kyellow.png macroscopic observation text Kyellow.png APSR 2.0
     Example
    example for use case #1
    <text>A. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)</text>
    Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11)
    Author

    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: 6.3.3.3 Macroscopic observation section
    Treeblank.png where [hl7:organizer]
    Treeblank.pngTreetree.png@typeCode
    cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    bl0 … 1Ftrue

    6.3.3.4 <Microscopic Observation> - Section Content Module - 1.3.6.1.4.1.19376.1.8.1.2.4

    6.3.3.4.1 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.

    6.3.3.4.2 Specification and Example
    Id1.3.6.1.4.1.19376.1.8.1.2.4Effective Date2014‑05‑13 14:25:17
    StatusKyellow.png DraftVersion Label2.0
    NameMicroscopySectionDisplay NameMicroscopic 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.
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.4
    LabelPaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section
    ClassificationCDA Section Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Associated with
    Associated with 2 concepts
    IdNameData Set
    psr-data​element-16Kyellow.png microscopic observation text Kyellow.png APSR 2.0
    psr-data​element-15Kyellow.png Microscopic 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
    RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
    Example
    example from use case #1
    <section classCode="DOCSECT">
      <templateId root="1.3.6.1.4.1.19376.1.8.1.2.4"/>  <code code="22635-7" displayName="Pathology report microscopic observation" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <title>MICROSCOPIC OBSERVATION SECTION</title>  <!-- Text: Human-readable part -->
      <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>
    </section>
    ItemDTCardConfDescriptionLabel
    hl7:section
    0 … 1RPaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section
     
    Target.png
    psr-data​element-15Kyellow.png Microscopic observation Kyellow.png APSR 2.0
     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.