| Item | DT | Card | Conf | Description | Label |
|---|
| | 0 … * | R | Problem organizer groups the observations and images investigating a single problem related to one or more specimens | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| |  | | psr-dataelement-39 |  Problem Organizer | APSR 2.0 |
|
 | @classCode
|
| cs | 1 … 1 | F | BATTERY |
| @moodCode
|
| cs | 1 … 1 | F | EVN |
| hl7:templateId
|
| II | 1 … 1 | M | | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
 | | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.8.1.3.6 |
| hl7:id
|
| II | 0 … * | R | | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| | | | psr-dataelement-86 | Problem ID | APSR 2.0 |
|
| hl7:code
|
| CD (required) | 0 … 1 | R | Problem
| PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| | @code
|
| CONF | 0 … 1 | F | 75326-9 |
| | @codeSystem
|
| 0 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) |
| | @codeSystemName
|
| 0 … 1 | F | LOINC |
| | @displayName
|
| 0 … 1 | F | Problem |
| hl7:statusCode
|
| CS (required) | 1 … 1 | M | The status of the organizer is "completed" if the battery of observations for this problem has been performed. It is "aborted" in case some of the intended observations could not be achieve and have been aborted, and appear as such below the organizer.
| PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| | 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_TS | 1 … 1 | M | Organizer time.
The period of time (possibly reduced to a point in time) during which the information was collected and assembled.
| PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| hl7:author
|
| | 0 … * | C | Author
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2
Contains 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11) | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| where [hl7:author] |
| |
| | Constraint | The author SHALL be present if it is different from the main author of the report. For instance the author could be the ordering physician contributing to the Clinical Information section, inside a report authored by the pathologist.
|
| hl7:informant
|
| | 0 … * | R | Informant
The informant is an actor (person and organization) who provided some of the clinical information carried by this organizer.
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.5
Contains 1.3.6.1.4.1.19376.1.8.1.4.6 Informant (2016‑07‑08 11:22:58) | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| hl7:participant
|
| | 0 … * | R | Transcriptionist, Device, Responsible, Validator
Source: PaLM 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 (2016‑07‑12 18:44:06) | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| where [hl7:participantRole] |
| |
| | Constraint | participationType "ENT", "DEV", "RESP", "AUTHEN"
|
| hl7:performer
|
| | 0 … 1 | C | Performing lab.
The performing laboratory is present at this level only if this particular problem on this particular specimen was investigated by a (subcontractor) distinct laboratory from the one issuing the consolidated report
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) | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| where [hl7:assignedEntity] |
| |
| Included | 0 … * | R | from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Specimen identification outside an AP observation for differentiating or restituting the problem type
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.9
|
| hl7:specimen
|
| | 0 … * | R | Required in XD-LAB when more than one specimen is documented at this level. Always required in APSR.
| PaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified |
| | | | psr-dataelement-17 | Specimen identification | APSR 2.0 |
|
| | @typeCode
|
| cs | 0 … 1 | F | SPC |
| | hl7:specimenRole
|
| | 1 … 1 | M | | PaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified |
| cs | 0 … 1 | F | SPEC |
| II | 1 … 1 | R | Specimen ID, coming from the LIS | PaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified |
| | | | psr-dataelement-95 | Parent ID | APSR 2.0 | | psr-dataelement-67 | Block ID | APSR 2.0 | | psr-dataelement-66 | Part ID | APSR 2.0 | | psr-dataelement-98 | Specimen ID | APSR 2.0 | | psr-dataelement-68 | Tissue section ID | APSR 2.0 |
|
| hl7:component
|
| | 0 … 1 | R | Coding of the Problem reported | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | hl7:observation
|
| | 0 … 1 | R | | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| CD (extensible) | 1 … 1 | R | | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| CONF | 0 … 1 | F | 75326-9 |
| 0 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) |
| 0 … 1 | F | LOINC |
| 0 … 1 | F | Problem |
| CR | 0 … * | R | Optional qualifier for separate problems with identical problem type in one specimen, e.g. a urothelial bladder cancer Invasive cancer) and a prostate cancer (invasive cancer) in one cystoprostatectomy specimen. The anatomic structure is able to differentiate.
| PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| | Example | Problem in urinary bladder in cystoprostatectomy specimen <qualifier>
<name code="116677004" codeSystem="2.16.840.1.113883.6.96" displayName="Associated topography (attribute)" codeSystemName="SNOMED-CT"/> <value code="302512001" codeSystem="2.16.840.1.113883.6.96" displayName=" Entire urinary bladder (body structure)" codeSystemName="SNOMED-CT"/></qualifier> |
| CV | 0 … 1 | R | | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| cs | 1 … 1 | F | 116677004 |
| oid | 1 … 1 | F | 2.16.840.1.113883.6.96 |
| st | 1 … 1 | F | Associated topography (attribute) |
| CD (extensible) | 0 … * | R | | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| CONF | 0 … 1 | F | << 91723000 |
| 0 … 1 | F | 2.16.840.1.113883.6.96 (SNOMED Clinical Terms) |
| 0 … 1 | F | SNOMED-CT |
| 0 … 1 | F | all values from Anatomical structure |
| CE (extensible) | 0 … 1 | R | Code of the problem reported | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| | CONF | | @code shall be "any_code" | | @codeSystem shall be "2.16.840.1.113883.6.3" | | @codeSystemName shall be "any_code" | | @displayName shall be "ICD-10" | | or | | The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.7 Problem Type (2016‑07‑11 09:52:19) |
|
| hl7:component
|
| | 0 … * | R | Any kind of AP observation, for complex observations, e.g. for TNM, ICD-O-3, or Assessment scales, the appropriate templates may be used.
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.7
Contains 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54) | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| where [hl7:observation [hl7:code [(@code = 'each_code_for_observable_entities_or_a_specific_procedure' and @codeSystem = '2.16.840.1.113883.6.1')]]] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | hl7:sequenceNumber
|
| INT | 0 … 1 | | | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| hl7:component
|
| | 0 … * | C | Laboratory observation
Contains 1.3.6.1.4.1.19376.1.3.1.6 Laboratory Observation (2008‑08‑08) | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| where [hl7:observation] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | hl7:sequenceNumber
|
| INT | 0 … 1 | | | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| hl7:component
|
| | 0 … * | R | Embedded image
This organizer may carry an image focusing on the problem, either directly embedded or encapsulated within a region of interest.
Contains 1.3.6.1.4.1.19376.1.8.1.4.10 Embedded Image (2016‑06‑22 16:08:01) | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| where [hl7:observationMedia] |
| |
| | @typeCode
|
| cs | 0 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | Constraint | [@classCode="ROIOVL" and moodCode="EVN"] |
| | hl7:sequenceNumber
|
| INT | 0 … 1 | | | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| hl7:component
|
| | 0 … * | R | Region of interest
This organizer may carry an image focusing on the problem, either directly embedded or encapsulated within a region of interest.
In the latter case by an entryRelationship @typeCode="SUBJ"
Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (2005‑09‑07) | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| where [hl7:regionOfInterest [hl7:code [@code = doc('include/voc-2.16.840.1.113883.1.11.16117-DYNAMIC.xml')//valueSet [1]/conceptList/*/@code or @nullFlavor]]] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | Constraint | [@classCode="ROIOVL" and moodCode="EVN"] |
| | hl7:sequenceNumber
|
| INT | 0 … 1 | | | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| hl7:component
|
| | 0 … * | R | General comment on this particular problem
Source: PCC TF-2: 6.3.4.6
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20) | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| where [hl7:act [hl7:code [(@code = '48767-8' and @codeSystem = '2.16.840.1.113883.6.1')]]] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |
| | hl7:sequenceNumber
|
| INT | 0 … 1 | | | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
| hl7:reference
|
| | 0 … * | R | Reference to an external document, or to external organizers, or to external observations, e.g. concerning molecular pathology or genetic testing report
Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07) | PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer |
Draft
