1.3.6.1.4.1.19376.1.3.10.9.43/static-2016-10-11T102617

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Id1.3.6.1.4.1.19376.1.3.10.9.43Effective Date2016‑10‑11 10:26:17
Other versions this id:
    Status DraftVersion Label2.0
    NameAssessmentScoringItemAPSR2.0Display NameAssessment Scoring Item APSR 2.0
    Description
    Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF)

    Supportive Observation entry template for describing the granular Items for a scoring system, e.g.Elston-Ellis-Score or Gleason Score
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.43
    ClassificationCDA Entry Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Used by / Uses
    Used by 0 transactions and 3 templates, Uses 5 templates
    Used by as NameVersion
    1.3.6.1.4.1.19376.1.3.10.9.42Containment Assessment Scoring System APSR 2.0 (2.0)2016‑10‑10 11:33:36
    1.3.6.1.4.1.19376.1.3.10.4.4 Assessment Scales Observation for Scoring Systems APSR2 (2.0)2016‑10‑06 13:12:00
    1.3.6.1.4.1.19376.1.3.10.4.3 ICD-O-3 Typing and Grading Observation (2.0)2015‑11‑29 17:03:18
    Uses as NameVersion
    1.3.6.1.4.1.19376.1.3.3.1.7Containment Laboratory Performer (2017)2008‑08‑08
    1.3.6.1.4.1.19376.1.8.1.4.2Containment CDA author IHE2016‑06‑21 14:02:11
    1.3.6.1.4.1.19376.1.8.1.4.6Containment CDA Informant(Header&Body) APSR2 (2.0)2016‑07‑08 11:22:58
    1.3.6.1.4.1.19376.1.8.1.4.7Containment Additional participant in an entry APSR (Body)2016‑07‑12 18:44:06
    1.3.6.1.4.1.19376.1.3.10.9.1Include X Specimen Identified2014‑12‑22 15:54:30
    RelationshipSpecialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 (2014‑05‑14 17:09:54)
    Example
    example for use case #1: ER-Allred Percentage Score Item
    <observation classCode="OBS" moodCode="EVN" negationInd="false">
      <templateId root="1.3.6.1.4.1.19376.1.3.10.9.43"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_AllredPercentage"/>  <code code="444644009" displayName="Number fraction of estrogen receptors in neoplasm using immune stain (observable entity)" codeSystem="2.16.840.1.113883.6.96"/>  <statusCode code="completed"/>  <effectiveTime>
        <low value="201001041405-0500"/>  </effectiveTime>      <value xsi:type="PQ" value="85" unit="%"/>  <methodCode code="0107" codeSystem="2.16.840.1.113883.5.84" displayName="Microscopy"/>  <performer>
        <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->
      </performer>      <author>
        <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->
      </author>      <informant>
        <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->
      </informant>      <participant>
        <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (2016-07-12T18:44:06) -->
      </participant>      <specimen typeCode="SPC">
        <specimenRole classCode="SPEC">
          <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_slide_A1_ER"/>    </specimenRole>      </specimen>    </observation>
    ItemDTCardConfDescriptionLabel
    hl7:observation
    		0 … *R(Ass...2.0)
    @classCode
    		cs1 … 1FOBS
    @moodCode
    		cs1 … 1FEVN
    @negationInd
    		bl0 … 1 
    hl7:templateId
    		II1 … 1M(Ass...2.0)
    @root
    		uid1 … 1F1.3.6.1.4.1.19376.1.3.10.9.43
    hl7:id
    		II0 … *R(Ass...2.0)
    hl7:code
    		CE (extensible)1 … 1M(Ass...2.0)
     CONF
    shall be drawn from concept domain "<<395527009 | Microscopic specimen observable (observable entity) |"
     Example
    for use case #1, Breast tubule formation
    <code code="371470008" codeSystem="2.16.840.1.113883.6.96"/>
    hl7:text
    		ED0 … 1R(Ass...2.0)
    hl7:statusCode
    		CS (required)1 … 1MThe observation statusCode is “ completed ” if the observation was actually performed and has produced a result in the  value  element. In other cases the status of the intended observation is “ aborted ” and the result will never come. 
    		(Ass...2.0)
     Constraint
    @code shall be "completed"
    or
    @code shall be "aborted"
     CONF
    The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (2014‑03‑26)
    hl7:effectiveTime
    		IVL_TS0 … 1R(Ass...2.0)
    hl7:value
    		INT1 … 1RSingle numerical score item of a scoring system, e.g. "2"  for Breast tubule formation(Ass...2.0)
     Example
    for use case #1
    <value value="2"/>
    hl7:interpretationCode
    		CE (extensible)0 … 1R(Ass...2.0)
     CONF
    The value of @code should be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)
    hl7:referenceRange
    		0 … 1R(Ass...2.0)
    @typeCode
    		cs1 … 1FREVF
    hl7:observationRange
    		0 … 1R(Ass...2.0)
    @classCode
    		cs1 … 1FOBS
    @moodCode
    		cs1 … 1FEVN.CRT
    hl7:code
    		CD (extensible)1 … 1R(Ass...2.0)
    @codeSystem
    		CONF0 … 1F2.16.840.1.113883.5.4 (Act Code)
    hl7:text
    		ED0 … 1R(Ass...2.0)
    hl7:effectiveTime
    		TS0 … 1R(Ass...2.0)
    hl7:value
    		ANY1 … 1R(Ass...2.0)
    hl7:interpretation
    		CD (extensible)0 … 1R(Ass...2.0)
     CONF
    The value of @code should be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)
    hl7:methodCode
    		CE (extensible)0 … 1R(Ass...2.0)
     CONF
    The value of @code should be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (2014‑03‑26)
    hl7:performer
    		II0 … *CPerforming lab

    Source: PaLM TF-3: 6.3.2.20

    Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)    		(Ass...2.0)
    where [hl7:assignedEntity]
    hl7:author
    		II0 … *CAuthor

    Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.2

    Contains 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)    		(Ass...2.0)
    where [hl7:author]
    hl7:informant
    		II0 … *RInformant

    Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.5

    Contains 1.3.6.1.4.1.19376.1.8.1.4.6 CDA Informant(Header&Body) APSR2 (2016‑07‑08 11:22:58)    		(Ass...2.0)
    hl7:participant
    		II0 … *RAdditional participants

    Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.6

    Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry APSR (Body) (2016‑07‑12 18:44:06)    		(Ass...2.0)
    where [hl7:participantRole]
    Included1 … *M from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
    hl7:specimen
    		1 … *MRequired in XD-LAB when more than one specimen is documented at this level. Always required in APSR.
    		PaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
     
    psr-data​element-17 Specimen identification  APSR 2.0
    @typeCode
    		cs0 … 1FSPC
    hl7:specimenRole
    		1 … 1MPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
    @classCode
    		cs0 … 1FSPEC
    hl7:id
    		II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.0‑3: 6.3.6.9 X Specimen identified
     
    psr-data​element-95 Parent ID  APSR 2.0
    psr-data​element-67 Block ID  APSR 2.0
    psr-data​element-68 Tissue section ID  APSR 2.0
    psr-data​element-98 Specimen ID  APSR 2.0
    psr-data​element-66 Part ID  APSR 2.0
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