Difference between revisions of "1.3.6.1.4.1.19376.1.8.1.2.5/static-2014-05-13T193126"
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− | <table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.5</td><th style="width: 20em; text-align: left;">Effective Date</th><td style="text-align: left;"> | + | <table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.2.5</td><th style="width: 20em; text-align: left;">Effective Date</th><td style="text-align: left;">2014‑05‑13 19:31:26</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Draft</td><th style="width: 20em; text-align: left;">Version Label</th><td style="text-align: left;">2.0</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">DiagnosticConclusionSection</td><th style="width: 20em; text-align: left;">Display Name</th><td style="text-align: left;">Diagnostic Conclusion Section</td></tr><td style="text-align: left;" colspan="4"><table class="treetable" id="templateDescTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Description</td></tr><tr><td><div><span lang="EN-US">The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.</span></div></td></tr></table></td><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Context</th><td style="text-align: left;" colspan="3">Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.5</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Label</th><td style="text-align: left;" colspan="3">PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section<br /></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Classification</th><td style="text-align: left;" colspan="3">CDA Section Level Template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Open/Closed</th><td style="text-align: left;" colspan="3">Open (other than defined elements are allowed)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Used by / Uses</th><td style="text-align: left;" colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Used by 0 transactions and 1 template, Uses 3 templates</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Used by</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.1.1</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Anatomic Pathology Structured Report Content Module (2.0)</td><td style="text-align: left;">2014‑05‑13 11:57:57</td></tr><tr><th style="width: 20%; text-align: left;">Uses</th><th style="width: 1%; text-align: left;"> as </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.4.2</td><td style="text-align: left;">Include</td><td style="text-align: left;">[[File:Kyellow.png|14px]] CDA author IHE</td><td style="text-align: left;">2016‑06‑21 14:02:11</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.3.10.4.5</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] CDA Update Information Organizer (2.0)</td><td style="text-align: left;">2017‑11‑14 15:22:14</td></tr><tr><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.3.6</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Problem Organizer (2.0)</td><td style="text-align: left;">2015‑08‑13 10:24:55</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Relationship</th><td style="text-align: left;" colspan="3">Specialization: template 2.16.840.1.113883.10.12.201 <i> </i> (2005‑09‑07)</td></tr><tr class="explabel" style="vertical-align: top;"><td style="width: 20em; text-align: left;">Example</td><td colspan="3" class="explabelgreen"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">example from use case #1</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">section</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">DOCSECT</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.8.1.2.5</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">22637-3</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Pathology report final diagnosis</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">title</span><span class="ppsign">></span><span class="pptext">DIAGNOSTIC CONCLUSION SECTION</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">text</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">paragraph</span><span class="ppsign">></span><span class="pptext"> A1. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">paragraph</span><span class="ppsign">></span></span> <span class="pptext"> <br /> INVASIVE ADENOCARCINOMA OF THE BREAST.</span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="pptext"><br /> HISTOLOGIC TYPE: DUCTAL.</span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="pptext"> NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3. <br /> </span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">list</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">item</span><span class="ppsign">></span><span class="pptext">TUBULE FORMATION SCORE: 2.</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">item</span><span class="ppsign">></span><span class="pptext">NUCLEAR PLEOMORPHISM SCORE: 2.</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">item</span><span class="ppsign">></span><span class="pptext">MITOTIC RATE SCORE: 1.</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">list</span><span class="ppsign">></span></span> <span class="pptext"> <br /> ICD-O-CLASSIFICATION: C50.3 M8500/31</span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="pptext"><br /> IN-SITU CARCINOMA: EQUIVOCAL.</span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">br</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="pptext"><br /> BREAST CANCER BIOMARKER STUDIES: <br /> </span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">list</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">item</span><span class="ppsign">></span><span class="pptext">PARAFFIN BLOCK NUMBER: A1.</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">item</span><span class="ppsign">></span><span class="pptext">ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8, Percentage stained tumor cells = 85%, Allred Staining Score = 3).</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">item</span><span class="ppsign">></span><span class="pptext">PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED SCORE = 8).</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">item</span><span class="ppsign">></span><span class="pptext">DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">item</span><span class="ppsign">></span><span class="pptext">HER2/NEU IMMUNOHISTOCHEMISTRY: EQUIVOCAL (2+) FOR OVEREXPRESSION OF HER2/NEU ONCOPROTEIN.</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">item</span><span class="ppsign">></span><span class="pptext">HER2/NEU FISH RESULTS: NOT AMPLIFIED.</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">list</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Start Level 3 for Diagnostic Conclusion--><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">entry</span><span class="ppsign">></span><br /><span style="display: block;"> <span style="color:green"><!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) 1..* R--><br /></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">entry</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">entry</span><span class="ppsign">></span><br /><span style="display: block;"> <span style="color:green"><!-- template 1.3.6.1.4.1.19376.1.3.10.4.5 'Update Information Organizer' (2017-11-14T15:22:14) 0..1 R --><br /></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">entry</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">></span></span></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Card</th><th style="width: 2em; text-align: left;">Conf</th><th style="text-align: left;">Description</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:section<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">DOCSECT</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@moodCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><p class="TableEntry" style="margin-top:6.0pt;margin-right:3.7pt;margin-bottom: 0cm;margin-left:0cm;margin-bottom:.0001pt"> |
<span lang="EN-US">This section SHALL contain a code element populated with these attributes:<span style="font-size: 12pt;"> | <span lang="EN-US">This section SHALL contain a code element populated with these attributes:<span style="font-size: 12pt;"> | ||
</span> | </span> |