| Item | DT | Card | Conf | Description | Label |
|---|
| | 0 … * | R | | PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
| |  | | psr-dataelement-47 |  ObservationReport | APSR 2.0 | | psr-dataelement-57 | Scoring systems | APSR 2.0 | | psr-dataelement-65 | Generic AP observation | APSR 2.0 |
|
 | @classCode
|
| cs | 1 … 1 | F | OBS |
| @moodCode
|
| cs | 1 … 1 | F | EVN |
| @negationInd
|
| bl | 0 … 1 | | |
| hl7:templateId
|
| II | 1 … 1 | M | | PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
 | | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.8.1.4.9 |
| hl7:id
|
| II | 0 … * | R | | PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
| hl7:code
|
| CE (extensible) | 1 … 1 | M | The Anatomic pathology observation code should be taken from a reference terminology, preferably the LOINC terminology. National terminologies may be used. | PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
| | @code
|
| CONF | 1 … 1 | F | each_code_for_observable_entities_or_a_specific_procedure |
| | @codeSystem
|
| 1 … 1 | F | 2.16.840.1.113883.6.1 (LOINC) |
| | @codeSystemName
|
| 1 … 1 | F | LOINC |
| | @displayName
|
| 1 … 1 | F | see_above |
| | Example | <code code="59847-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Histology and Behavior ICD-O-3"/> |
| hl7:text
|
| ED | 0 … 1 | R | Narrative text about the observation | PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
| hl7:statusCode
|
| CS (required) | 1 … 1 | M | The observation statusCode is “completed” if the observation was actually performed and has produced a result in the valueelement. In other cases the status of the intended observation is “aborted” and the result will never come. | PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
| | 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 | Date and time the observation has been made | PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
| hl7:value
|
| ANY | 0 … * | R | Observation values using the appropriate data type.
Numeric results use data type PQ, which includes the unit. The result is absent in case of ‘aborted’ observation.
| PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
| | Constraint | The default data type, cardinalities and value set for the <value> element are dependant on the type of observation. |
| | CONF | | The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.11 AP Observation (2015‑11‑22 12:20:34) |
|
| | Example | for observation on tumor type <value code="8500/3" codeSystem="2.16.840.1.113883.6.43.1" codeSystemName="ICD-O-3" displayName="Invasive carcinoma of the breast, no special type"/> |
| hl7:interpretationCode
|
| CE (extensible) | 0 … 1 | R | One or more codes interpreting the result, expressed with ObservationInterpretation vocabulary (e.g., H = high, L = low). This element may be coded with other values than those of the ObservationInterpretation vocabulary, given that the coding strength is CWE (coded with exceptions).
| PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
| | CONF | | The value of @code should be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26) |
|
| hl7:methodCode
|
| CE (extensible) | 0 … 1 | R | | PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
| | CONF | | The value of @code should be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (2014‑03‑26) |
|
| 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 TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
| | 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 TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
| 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 TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
| 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 TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
| hl7:entryRelationship
|
| | 0 … * | R | Sub-Observation
The result obtained for an observation may lead to an additional AP observation to refine this result. This sub-observation is again an Anatomic Pathology Observation.
Source: Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.7
Contains 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54) | PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| hl7:entryRelationship
|
| | 0 … * | R | Embedded image.
This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest.
Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.8
Contains 1.3.6.1.4.1.19376.1.8.1.4.10 Embedded Image (2016‑06‑22 16:08:01) | PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| hl7:entryRelationship
|
| | 0 … * | R | Region of Interest
Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (2005‑09‑07) | PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | Constraint | This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest.
In the latter case by an entryRelationship @typeCode="SUBJ" |
| hl7:entryRelationship
|
| | 0 … * | R | Annotation comment
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20) | PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
| | @typeCode
|
| cs | 0 … 1 | F | COMP |
| Included | 1 … * | M | from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Specimen identification |
| | Example | Example for specimen referencing <specimen>
<!-- which specimen is used for this observation -->
<specimenRole>
<id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="slide_A_1_PR"/> </specimenRole></specimen> |
| hl7:specimen
|
| | 1 … * | M | 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-dataelement-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 |
| cs | 0 … 1 | F | SPEC |
| II | 1 … 1 | R | Specimen ID, coming from the LIS | PaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified |
| | | | psr-dataelement-66 | Part ID | APSR 2.0 | | psr-dataelement-67 | Block ID | APSR 2.0 | | psr-dataelement-68 | Tissue section ID | APSR 2.0 | | psr-dataelement-95 | Parent ID | APSR 2.0 | | psr-dataelement-98 | Specimen ID | APSR 2.0 |
|
| hl7:reference
|
| | 0 … * | R | Reference to an external document, or to external observations, e.g. concerning molecular pathology or genetic testing report
Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07) | PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation |
Draft
