| Item | DT | Card | Conf | Description | Label |
|---|
| | 1 … 1 | M | | PaLM Suppl. 2.1‑3: 6.3.3.6 Diagnostic conclusion section |
| |  | | psr-dataelement-45 |  Diagnosis |  APSR 2.0 | | psr-dataelement-3 | Tumor formula (TNM) | APSR 2.0 | | psr-dataelement-54 | Tumor classification (ICD-O-3) | APSR 2.0 |
|
 | @classCode
|
| cs | 1 … 1 | F | DOCSECT |
| @moodCode
|
| cs | 1 … 1 | F | EVN |
| | Constraint |
This section SHALL contain a code element populated with these attributes:
@code
="22637-3"
@codeSystem
="2.16.840.1.113883.6.1"
@displayName
="Pathology report diagnosis"
This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.
The section SHALL contain as many Problem Organizer entry elements as there are problems or groups thereof investigated. Each entry provides machine-readable data.
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: 6.3.3.6 Diagnostic conclusion section |
 | | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.8.1.2.5 |
| hl7:code
|
| CE | 1 … 1 | M | | PaLM Suppl. 2.1‑3: 6.3.3.6 Diagnostic conclusion section |
| | @code
|
| CONF | 1 … 1 | F | 22637-3 |
| | @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 diagnosis |
| hl7:title
|
| ST | 1 … 1 | R | The Diagnostic Conclusion Section<title> SHALL be present. It is the local translation of the code@displayName
| PaLM Suppl. 2.1‑3: 6.3.3.6 Diagnostic conclusion section |
| | Example | <hl7:title>Pathology Final Diagnosis</hl7:title> |
| hl7:text
|
| SD.TEXT | 1 … 1 | M | | PaLM Suppl. 2.1‑3: 6.3.3.6 Diagnostic conclusion section |
| | Example | example for use case#1 <text>
<paragraph> A1. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)
</paragraph>
INVASIVE ADENOCARCINOMA OF THE BREAST. <br/>
HISTOLOGIC TYPE: DUCTAL. <br/> NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3.
<list>
<item>TUBULE FORMATION SCORE: 2.</item> <item>NUCLEAR PLEOMORPHISM SCORE: 2.</item> <item>MITOTIC RATE SCORE: 1.</item> </list>
ICD-O-CLASSIFICATION: C50.3 M8500/31 <br/>
IN-SITU CARCINOMA: EQUIVOCAL. <br/> <br/>
BREAST CANCER BIOMARKER STUDIES:
<list>
<item>PARAFFIN BLOCK NUMBER: A1.</item> <item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED
SCORE = 8, Percentage stained tumor cells = 85%, Allred Staining Score = 3).</item> <item>PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED
SCORE = 8).</item> <item>DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR
EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.</item> <item>HER2/NEU IMMUNOHISTOCHEMISTRY: EQUIVOCAL (2+) FOR OVEREXPRESSION
OF HER2/NEU ONCOPROTEIN.</item> <item>HER2/NEU FISH RESULTS: NOT AMPLIFIED.</item> </list></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-dataelement-4 | Pathologist | APSR 2.0 | | psr-dataelement-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 |
| 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 |
| cs | 0 … 1 | F | ASSIGNED |
| II | 1 … * | M | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| AD | 1 … * | M | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| | | | psr-dataelement-18 | Address | APSR 2.0 |
|
| 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:assignedPerson
- hl7:assignedAuthoringDevice
|
| | 0 … 1 | C | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| | | | psr-dataelement-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. |
| | 0 … 1 | F | PSN |
| | 0 … 1 | F | INSTANCE |
| PN | 1 … 1 | R | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| | | | hl7:assignedAuthoringDevice
|
| | 0 … 1 | C | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| cs | 0 … 1 | F | DEV |
| cs | 0 … 1 | F | INSTANCE |
| | | | | hl7:manufacturerModelName
|
| SC | 0 … 1 | R | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| SC | 0 … 1 | R | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| CE | 0 … 1 | R | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| | | hl7:representedOrganization
|
| | 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. |
| | 0 … 1 | F | ORG |
| | 0 … 1 | F | INSTANCE |
| II | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| ON | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| TEL | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| 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 |
| | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| | 0 … 1 | F | PART |
| II | 0 … * | R | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| CE | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| CONF | 0 … 1 | F | 2.16.840.1.113883.5.111 (Role Code) |
| 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) |
|
| IVL_TS | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| | 0 … 1 | F | ORG |
| | 0 … 1 | F | INSTANCE |
| II | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| ON | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| TEL | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author |
| 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 … 1 | C | Source: PaLM Suppl. APSR 2.0-3: 6.2.5.4
Contains 1.3.6.1.4.1.19376.1.3.10.4.5 Update Information Organizer (2017‑11‑14 15:22:14) | PaLM Suppl. 2.1‑3: 6.3.3.6 Diagnostic conclusion section |
| where [hl7:organizer] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | Constraint | if ClinicalDocument.versionNumber > 1 |
| hl7:entry
|
| | 1 … * | M | 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: 6.3.3.6 Diagnostic conclusion section |
| where [not(@nullFlavor)] [hl7:organizer] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
Draft
