1.3.6.1.4.1.19376.1.3.10.3.1/static-2016-11-13T142808

Id	1.3.6.1.4.1.19376.1.3.10.3.1	Effective Date	2016‑11‑13 14:28:08
Status	Draft	Version Label	2.0
Name	AdditionalSpecifiedObservationSection	Display Name	Additional Specified Observation Section
Description Template CDA Section (prototype, directly derived from POCD_RM000040 MIF) The Additional Specified Observation section includes additional pathologic finding(s) and the results of ancillary study(yes) with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken.  Further CDA content section modules as subsections are allowed.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.3.1
Label	PaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section
Classification	CDA Section Level Template
Open/Closed	Open (other than defined elements are allowed)
Associated with	Associated with 1 concept Id Name Data Set psr-data​element-96  Additional Specified Observation  APSR 2.0
Uses	Uses 2 templates Uses as Name Version 1.3.6.1.4.1.19376.1.8.1.4.2 Include Author (2.0) 2016‑06‑21 14:02:11 1.3.6.1.4.1.19376.1.8.1.3.6 Containment Problem Organizer (2.0) 2015‑08‑13 10:24:55
Relationship	Adaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07) ref ad1bbr-
Example	generated example <section classCode="DOCSECT" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.3.10.3.1"/>  <code code="xxxxx-x" codeSystem="2.16.840.1.113883.6.1" displayName="specified observation"/>  <title>ADDITIONAL SPECIFIED OBSERVATION SECTION</title>  <text/>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016‑06‑21 14:02:11) -->   </author>  <entry 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></section>
Item DT Card Conf Description Label hl7:section 0 … * R PaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section   psr-data​element-96  Additional Specified Observation  APSR 2.0 @classCode cs 0 … 1 F DOCSECT @moodCode cs 0 … 1 F EVN   Constraint This section SHALL contain a code element populated with these attributes: @code="xxxxx-x" (specific for the additional specified observation) @codeSystem="2.16.840.1.113883.6.1"  @displayName="Pathology report yyyyy (specific) observation"   This section SHALL contain a narrative block, represented by a textelement, 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 MAY contain subsections.  hl7:templateId II 1 … 1 M PaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.10.3.1 hl7:code CE 1 … 1 M PaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section   Constraint The LOINC code SHALL be chosen according the specified observation type @code CONF 1 … 1 F xxxxx-x @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (LOINC) @codeSystemName 1 … 1 F LOINC @displayName 1 … 1 F specified observation hl7:title ST 1 … 1 R PaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section   Example MP observation <text>MOLECULAR PATHOLOGY OBSERVATION SECTION</text> hl7:text SD.TEXT 1 … 1 M PaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section Included 0 … * 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  hl7:author 0 … * C PaLM 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 cs 1 … 1 F AUT   Example author is a person <author typeCode="AUT" contextControlCode="OP">   <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">     <!-- ... -->   </assignedAuthor></author> hl7:templateId 1 … 1 M PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.4.2 hl7:time TS 1 … 1 M The 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 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author @classCode cs 0 … 1 F ASSIGNED hl7:id II 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:addr AD 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author   psr-data​element-18  Address  APSR 2.0 hl7:telecom TEL 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author Choice 1 … 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 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author   psr-data​element-5  Name  APSR 2.0 Included 1 … 1 R from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07) The name(s) SHALL be given. @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 1 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:softwareName SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:code CE 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:represented​Organization 0 … 1 PaLM 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> Included 0 … 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 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:name ON 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:telecom TEL 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:addr AD 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:standard​Industry​Class​Code CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:asOrganizationPartOf 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author @classCode 0 … 1 F PART hl7:id II 0 … * R PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:code CE 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author   CONF shall be drawn from concept domain "RoleCode" hl7:statusCode CS 0 … 1 PaLM 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_TS 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:wholeOrganization 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:name ON 0 … * PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:telecom TEL 0 … * PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:addr AD 0 … * PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:standard​Industry​Class​Code CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:entry 0 … * R Source: 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: 6.3.3.5 Addtional specified observation section @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true