1.3.6.1.4.1.19376.1.8.1.2.6/static-2014-05-13T193312

Id	1.3.6.1.4.1.19376.1.8.1.2.6	Effective Date	2014‑05‑13 19:33:12
Status	Draft	Version Label	2.0
Name	ProcedureStepsSection	Display Name	Procedure Steps Section
Description The Procedure steps section contains the description of tissue dissection: representative specimens and derived specimens dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, electron microscopy, etc.) or biorepository.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.6
Label	PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section
Classification	CDA Section Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 1 template, Uses 2 templates Used by as Name Version 1.3.6.1.4.1.19376.1.8.1.1.1 Containment Anatomic Pathology Structured Report Content Module (2.0) 2014‑05‑13 11:57:57 Uses as Name Version 1.3.6.1.4.1.19376.1.8.1.4.2 Include CDA author IHE 2016‑06‑21 14:02:11 1.3.6.1.4.1.19376.1.3.10.4.1 Containment Specimen Procedure Step (2.0) 2016‑07‑08 13:20:59
Relationship	Specialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example	example from use case #1 <section classCode="DOCSECT" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.8.1.2.6"/>  <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008"/>  <code code="46059-2" codeSystem="2.16.840.1.113883.6.1" displayName="Special treatments and procedures section"/>  <title>PROCEDURE STEPS SECTION</title>  <!--list and hierarchy of specimens, parts, blocks and slides. Parts are here a theoretical construction for assigning gross description observations -->   <text>      RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)    <br/>     PARAFFIN BLOCK NUMBER: A1.:FOUR SECTIONS FOR EACH STAIN:    <br/>    <paragraph ID="A7102400008">RIGHT BREAST FIVE CORES 8-9:00</paragraph>    <paragraph ID="block_A_1">PARAFFIN BLOCK NUMBER: A1</paragraph>    <paragraph ID="slide_A_1_HE">slide from block A1 HE stained</paragraph>    <paragraph ID="slide_A_1_ER">slide from block A1 ER Immunohistochemistry</paragraph>    <paragraph ID="slide_A_1_PR">slide from block A1 PR Immunohistochemistry</paragraph>    <paragraph ID="slide_A_1_EGFR">slide from block A1 EGFR (PharmDX) Immunohistochemistry</paragraph>    <paragraph ID="slide_A_1_HER2">slide from block A1 HER2 Immunohistochemistry</paragraph>    <paragraph ID="slide_A_1_HER2_FISH">slide block from A1 HER2 FISH</paragraph>  </text>  <entry typeCode="COMP" contextConductionInd="false">     <!-- template 1.3.6.1.4.1.19376.1.3.10.4.1 'Specimen Procedure Step' (2016-07-08T13:20:59) -->   </entry></section>
Item DT Card Conf Description Label hl7:section 0 … 1 R PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section @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 ="46059-2" @codeSystem ="2.16.840.1.113883.6.1" @displayName ="Special treatments and procedures section"  This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader. This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document. The section SHOULD contain as many Specimen Procedure Steps entry elements as there are procedure steps or groups thereof to be described. These entries provide the machine-readable data corresponding to the narrative block.  hl7:templateId II 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.2.6 hl7:code CE 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section @code CONF 1 … 1 F 46059-2 @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 Special treatments and procedures section hl7:title ST 1 … 1 R The Procedure Steps Section<title> SHALL be present. It is the local translation of the code@displayName  PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section hl7:text SD.TEXT 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section   Example example for use case#1 <text>    RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)  <br/>   PARAFFIN BLOCK NUMBER: A1.:FOUR SECTIONS FOR EACH STAIN:  <br/>  <paragraph ID="A7102400008">RIGHT BREAST FIVE CORES 8-9:00</paragraph>  <paragraph ID="block_A_1">PARAFFIN BLOCK NUMBER: A1</paragraph>  <paragraph ID="slide_A_1_HE">slide from block A1 HE stained</paragraph>  <paragraph ID="slide_A_1_ER">slide from block A1 ER Immunohistochemistry</paragraph>  <paragraph ID="slide_A_1_PR">slide from block A1 PR Immunohistochemistry</paragraph>  <paragraph ID="slide_A_1_EGFR">slide from block A1 EGFR (PharmDX) Immunohistochemistry</paragraph>  <paragraph ID="slide_A_1_HER2">slide from block A1 HER2 Immunohistochemistry</paragraph>  <paragraph ID="slide_A_1_HER2_FISH">slide block from A1 HER2 FISH</paragraph></text> Included 0 … * 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 … * C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @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 2.0‑3:6.3.6.2 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 2.0‑3:6.3.6.2 Author hl7:assignedAuthor 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F ASSIGNED hl7:id II 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 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 2.0‑3:6.3.6.2 Author 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 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 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 2.0‑3:6.3.6.2 Author hl7:softwareName SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:represented​Organization 0 … 1 PaLM 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> 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 2.0‑3:6.3.6.2 Author hl7:name ON 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:asOrganizationPartOf 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F PART hl7:id II 0 … * R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.111 (Role Code) hl7:statusCode CS 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 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_TS 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:wholeOrganization 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:entry 0 … * R Specimen procedure steps  Source: PaLM Suppl.APSR 2.0‑3:6.2.5.3 Contains 1.3.6.1.4.1.19376.1.3.10.4.1 Specimen Procedure Step (2016‑07‑08 13:20:59) PaLM Suppl. 2.0‑3: 6.3.4.7 Procedure steps section where [@typeCode='COMP'] [hl7:procedure [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.4.1']]] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1