1.3.6.1.4.1.19376.1.8.1.2.7/static-2016-06-13T175442: Difference between revisions

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<table
<table

Latest revision as of 15:30, 22 June 2022

Id1.3.6.1.4.1.19376.1.8.1.2.7Effective Date2016‑06‑13 17:54:42
Status CancelledVersion Label2.0
NameReportTextualSummaryDisplay NameReport Textual Summary Section
Description
Template CDA Section (prototype, directly derived from POCD_RM000040 MIF)

The Report Textual Summary section is an optional sub-section of the Diagnostic Conclusion section. This section contains a textual summary of the AP report, which can be extracted from the document and inserted into other clinical documents. It addresses the use case where authors of other medical documents feel the need to include a segment such as "...the pathology report states '[...]'", the text content of this section filling the brackets.


ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.7
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 1 template
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.2Include Author (2.0)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
hl7:section
0 … 1R(Rep...ary)
@classCode
cs0 … 1FDOCSECT
@moodCode
cs0 … 1FEVN
 Constraint

This section SHALL contain a code element populated with these attributes:

@code="35660-0" 

@codeSystem="2.16.840.1.113883.6.1" 

@displayName="Pathology report final diagnosis section - text"  

This section SHALL contains a narrative block, represented by a text element, which renders the information to the human reader.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

The section SHALL does not contain any entry element or any sub-section. 


hl7:templateId
II1 … 1M(Rep...ary)
@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.7
hl7:templateId
II1 … 1R(Rep...ary)
@root
uid1 … 1F2.16.840.1.113883.10.12.201
hl7:id
II0 … 1R(Rep...ary)
hl7:code
CE1 … 1M(Rep...ary)
@code
CONF1 … 1F35660-0
@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
@displayName
1 … 1FPathology report final diagnosis section - text
@codeSystemName
1 … 1FLOINC
hl7:title
ST1 … 1R(Rep...ary)
 CONF
element content shall be "Report Textual Summary"
hl7:text
SD.TEXT1 … 1M(Rep...ary)
hl7:confidentialityCode
CE0 … 1(Rep...ary)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)
hl7:language​Code
CS0 … 1(Rep...ary)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:author
0 … *CSource: PAT TF-3:6.2.6.2(Rep...ary)
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 Author (DYNAMIC)
hl7:author
0 … *CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
 
psr-data​element-4 Pathologist  APSR 2.0
psr-data​element-79 Device  APSR 2.0
@typeCode
cs1 … 1FAUT
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor>
</author>
hl7:templateId
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
hl7: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
hl7:assignedAuthor
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
@classCode
cs0 … 1FASSIGNED
hl7:id
II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:addr
AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
 
psr-data​element-18 Address  APSR 2.0
hl7: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
hl7:assigned​Person
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
 
psr-data​element-5 Name  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.
@classCode
0 … 1FPSN
@determiner​Code
0 … 1FINSTANCE
hl7:name
PN1 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:assigned​Authoring​Device
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
@classCode
cs0 … 1FDEV
@determiner​Code
cs0 … 1FINSTANCE
hl7:manufacturer​Model​Name
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:softwareName
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:code
CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7: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.
@classCode
0 … 1FORG
@determiner​Code
0 … 1FINSTANCE
hl7:id
II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:name
ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:telecom
TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:standard​Industry​Class​Code
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:asOrganizationPartOf
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
@classCode
0 … 1FPART
hl7:id
II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
 CONF
shall be drawn from concept domain "RoleCode"
hl7: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)
hl7:effectiveTime
IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:wholeOrganization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
@classCode
0 … 1FORG
@determiner​Code
0 … 1FINSTANCE
hl7:id
II0 … *PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:name
ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:addr
AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:standard​Industry​Class​Code
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author