1.3.6.1.4.1.19376.1.3.10.4.4/static-2016-10-06T131200

Id	1.3.6.1.4.1.19376.1.3.10.4.4	Effective Date	2016‑10‑06 13:12:00 Other versions this id: AssessmentScalesScoringSystemsAPSR as of 2016‑10‑06 12:36:29 CDASupplyContainerAPSR2 as of 2016‑07‑29
Status	Draft	Version Label	2.0
Name	AssessmentScalesObservationScoringSystemsAPSR	Display Name	Assessment Scales Observation for Scoring Systems
Description Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF) Assessment scale observation for Scoring Systems, e.g. Nottingham- (Elston-Ellis-) Grading for invasive breast cancers, describing the summarized scale value
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.4
Label	PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
Classification	CDA Entry Level Template
Open/Closed	Closed (only defined elements are allowed)
Associated with	Associated with 1 concept Id Name Data Set psr-data​element-99  Assessment Scales  APSR 2.0
Uses	Uses 7 templates Uses as Name Version 1.3.6.1.4.1.19376.1.3.3.1.7 Containment Laboratory Performer (2017) 2008‑08‑08 1.3.6.1.4.1.19376.1.8.1.4.2 Containment Author (2.0) 2016‑06‑21 14:02:11 1.3.6.1.4.1.19376.1.8.1.4.6 Containment Informant (2.0) 2016‑07‑08 11:22:58 1.3.6.1.4.1.19376.1.8.1.4.7 Containment Additional participant in an entry (2.0) 2016‑07‑12 18:44:06 1.3.6.1.4.1.19376.1.3.10.9.1 Include X Specimen Identified (2.0) 2014‑12‑22 15:54:30 1.3.6.1.4.1.19376.1.3.10.9.42 Containment Assessment Scoring System APSR 2.0 (2.0) 2016‑10‑10 11:33:36 2.16.840.1.113883.10.12.324 Containment CDA Reference 2005‑09‑07
Relationship	Specialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54)
Example	example for use case #1, ER-Allred Score <observation classCode="OBS" moodCode="EVN" negationInd="false">   <templateId root="1.3.6.1.4.1.19376.1.8.1.4.9"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_AllredScore"/>  <code code="445104009" codeSystem="2.16.840.1.113883.6.96" displayName="Allred score"/>  <statusCode code="completed"/>  <effectiveTime>     <low value="201001041405-0500"/>  </effectiveTime>  <value xsi:type="PQ" value="8"/>  <interpretationCode code="RR" displayName="Reactive" codeSystem="2.16.840.1.113883.5.83"/>  <methodCode code="0114" codeSystem="2.16.840.1.113883.1.11.14079" displayName="Microscopy, Light"/>  <performer>     <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->   </performer>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->   </author>  <informant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->   </informant>  <participant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (2016-07-12T18:44:06) -->   </participant>  <specimen typeCode="SPC">     <specimenRole classCode="SPEC">       <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_slide_A1_ER"/>    </specimenRole>  </specimen>  <entryRelationship typeCode="SPRT">     <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.42 'Assessment Scoring System APSR 2.0' (2016-10-10T11:33:36) -->   </entryRelationship></observation>
Item DT Card Conf Description Label hl7:observation 0 … 1 R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales   psr-data​element-99  Assessment Scales  APSR 2.0 @classCode cs 0 … 1 F OBS @moodCode cs 1 … 1 F EVN @negationInd bl 0 … 1   hl7:templateId II 1 … 1 M PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.10.4.4 hl7:id II 0 … * R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales hl7:code CE (extensible) 1 … 1 M Assessment scale, e.g. grading by scoring PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales   CONF @code shall be "273249006" @codeSystem shall be "2.16.840.1.113883.6.96" @codeSystemName shall be "SCT" @displayName shall be "Assessment scales" or The value of @code should be drawn from value set 2.16.840.1.113883.1.11.19918 ActCoverageAssessmentObservationValue (2014‑03‑26)   Example for use case #1 <code code="273249006" codeSystem="2.16.840.1.113883.6.96" displayName="Assessment scales (assessment scale)"/> hl7:derivationExpr ST 0 … 1 R This optional field can be used to specify how the total score is calculated. In most cases the total score will be the sum of its components. But complex mathematical functions and/or logical operations are possible as well. PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales hl7:text ED 0 … 1 R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales   Example for use case #1 <text>Nottingham combined grad I (1 of 3)</text> hl7:statusCode CS 1 … 1 M The observation statusCode is “ completed ” if the observation was actually performed and has produced a result in the  value  element. In other cases the status of the intended observation is “ aborted ” and the result will never come.  PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales   Constraint @code shall be "completed" or @code shall be "aborted"   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (2014‑03‑26) hl7:effectiveTime IVL_TS 1 … 1 M PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales hl7:value ANY 1 … * R any total value of a scoring systems, e.g. Gleason score, van Nuys score, etc., either with data type INT or with data type CD or CO  PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales   Example for use case #1, Nottingham combined grade I <value value="1"/> hl7:interpretationCode CE 0 … * R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26) hl7:methodCode CE 0 … * R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales @code CONF 0 … 1 F 0114 @codeSystem 0 … 1 F 2.16.840.1.113883.1.11.14079 (v3 Code System ObservationMethod) @codeSystemName 0 … 1 F HL7 @displayName 0 … 1 F Microscopy, Light hl7:performer II 0 … 1 C Performing lab Source: PaLM TF-3: 6.3.2.20 Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08) PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales   Constraint The performing laboratory is present at this level only if this particular observation was performed by a (subcontractor) laboratory distinct from the one issuing the rest of the observations in this organizer. hl7:author II 0 … * C Author Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.2 Contains 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11) PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales hl7:informant II 0 … * R Informant Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.5 Contains 1.3.6.1.4.1.19376.1.8.1.4.6 Informant (2016‑07‑08 11:22:58) PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales hl7:participant II 0 … * R Additional participants Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.6 Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry (2016‑07‑12 18:44:06) PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales Included 0 … * R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30) hl7:specimen 0 … * R Required in XD-LAB when more than one specimen is documented at this level. Always required in APSR. PaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified   psr-data​element-17  Specimen identification  APSR 2.0 @typeCode cs 0 … 1 F SPC hl7:specimenRole 1 … 1 M PaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified @classCode cs 0 … 1 F SPEC hl7:id II 1 … 1 R Specimen ID, coming from the LIS PaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified   psr-data​element-66  Part ID  APSR 2.0 psr-data​element-67  Block ID  APSR 2.0 psr-data​element-68  Tissue section ID  APSR 2.0 psr-data​element-95  Parent ID  APSR 2.0 psr-data​element-98  Specimen ID  APSR 2.0 hl7:entryRelationship 0 … * R Contains 1.3.6.1.4.1.19376.1.3.10.9.42 Assessment Scoring System APSR 2.0 (2016‑10‑10 11:33:36) PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales @typeCode cs 1 … 1 F SPRT hl7:sequenceNumber INT 0 … 1 PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales hl7:reference 0 … * R Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07) PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales hl7:referenceRange 0 … * R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales @typeCode cs 1 … 1 F REFV hl7:observationRange 1 … 1 R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales @classCode cs 0 … 1 F OBS @moodCode cs 0 … 1 F EVN.CRT hl7:code CD 0 … 1 PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.4 (Act Code) hl7:text ED 0 … 1 PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales hl7:value ANY 0 … 1 PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales hl7:interpretationCode CE 0 … 1 PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)