1.3.6.1.4.1.19376.1.8.1.2.3/static-2014-05-13T115709: Difference between revisions

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Revision as of 15:34, 31 July 2018

Id1.3.6.1.4.1.19376.1.8.1.2.3Effective Date2014‑05‑13 11:57:09
Other versions this id:
    Status 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. 2.0‑3: 6.3.4.3 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-31 macroscopic observation text  APSR 2.0
    psr-data​element-30 Macroscopic observation  APSR 2.0
    Used by / Uses
    Used by 0 transactions and 1 template, Uses 2 templates
    Used by as NameVersion
    1.3.6.1.4.1.19376.1.8.1.1.1Containment Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
    Uses as NameVersion
    1.3.6.1.4.1.19376.1.8.1.4.2Include CDA author IHE2016‑06‑21 14:02:11
    1.3.6.1.4.1.19376.1.8.1.3.6Containment 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. 2.0‑3: 6.3.4.3 Macroscopic observation section
     
    psr-data​element-30 Macroscopic observation  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.

    hl7:templateId
    		II1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
    @root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.3
    hl7:code
    		CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
    @code
    		CONF1 … 1F22634-0
    @codeSystem
    		1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
    @codeSystemName
    		1 … 1FLOINC
    @displayName
    		1 … 1FPathology report gross observation
    hl7:title
    		ST1 … 1RThe Macroscopic Observation Section<title> SHALL be present. It is the local translation of the code@displayName 
    		PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
     Example<title>Macroscopic Observation</title>
    hl7:text
    		SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section
     
    psr-data​element-31 macroscopic observation text  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 CDA author IHE (2016‑06‑21 14:02:11)
    Author

    Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2
    hl7:author
    		0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 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 2.0‑3:6.3.6.2 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 2.0‑3:6.3.6.2 Author
    hl7:assignedAuthor
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    @classCode
    		cs0 … 1FASSIGNED
    hl7:id
    		II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    hl7:addr
    		AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
     
    psr-data​element-18 Address  APSR 2.0
    hl7:telecom
    		TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 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 2.0‑3:6.3.6.2 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 2.0‑3:6.3.6.2 Author
    hl7:assigned​Authoring​Device
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    @classCode
    		cs0 … 1FDEV
    @determiner​Code
    		cs0 … 1FINSTANCE
    hl7:manufacturer​Model​Name
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    hl7:softwareName
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    hl7:code
    		CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    hl7:represented​Organization
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 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 2.0‑3:6.3.6.2 Author
    hl7:name
    		ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    hl7:telecom
    		TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    hl7:addr
    		AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    hl7:standardIndustryClassCode
    		CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    hl7:asOrganizationPartOf
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    @classCode
    		0 … 1FPART
    hl7:id
    		II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    hl7:code
    		CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    @codeSystem
    		CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
    hl7:statusCode
    		CS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 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 2.0‑3:6.3.6.2 Author
    hl7:wholeOrganization
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    @classCode
    		0 … 1FORG
    @determiner​Code
    		0 … 1FINSTANCE
    hl7:id
    		II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    hl7:name
    		ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    hl7:telecom
    		TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    hl7:addr
    		AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    hl7:standardIndustryClassCode
    		CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    hl7: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. 2.0‑3: 6.3.4.3 Macroscopic observation section
    where [hl7:organizer]
    @typeCode
    		cs1 … 1FCOMP
    @context​Conduction​Ind
    		bl0 … 1Ftrue
    Retrieved from "http://pubswiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.8.1.2.3/static-2014-05-13T115709&oldid=1556"