1.3.6.1.4.1.19376.1.8.1.2.3/static-2014-05-13T115709

Id	1.3.6.1.4.1.19376.1.8.1.2.3	Effective Date	2014‑05‑13 11:57:09 Other versions this id:
Status	Draft	Version Label	2.0
Name	MacroscopySection	Display Name	Macroscopic 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.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.3
Label	PaLM Suppl. 2.1‑3: 6.3.3.3 Macroscopic observation section
Classification	CDA Section Level Template
Open/Closed	Open (other than defined elements are allowed)
Associated with	Associated with 2 concepts Id Name Data Set psr-data​element-31  macroscopic observation text  APSR 2.0 psr-data​element-30  Macroscopic 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	Specialization: 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>
Item DT Card Conf Description Label hl7:section 0 … 1 R PaLM Suppl. 2.1‑3: 6.3.3.3 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 II 1 … 1 M PaLM Suppl. 2.1‑3: 6.3.3.3 Macroscopic observation section @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.2.3 hl7:code CE 1 … 1 M PaLM Suppl. 2.1‑3: 6.3.3.3 Macroscopic observation section @code CONF 1 … 1 F 22634-0 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) @codeSystemName 1 … 1 F LOINC @displayName 1 … 1 F Pathology report gross observation hl7:title ST 1 … 1 R The Macroscopic Observation Section<title> SHALL be present. It is the local translation of the code@displayName  PaLM Suppl. 2.1‑3: 6.3.3.3 Macroscopic observation section   Example <title>Macroscopic Observation</title> hl7:text SD.TEXT 1 … 1 M PaLM Suppl. 2.1‑3: 6.3.3.3 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> Included 0 … * C from 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11) Author 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:standardIndustryClassCode 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 @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.111 (Role Code) 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:standardIndustryClassCode 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: 6.3.3.3 Macroscopic observation section where [hl7:organizer] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true