1.3.6.1.4.1.19376.1.3.10.9.28

Template TNMGrading

Description

Template CDA Observation (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF)

Actual version

Id	1.3.6.1.4.1.19376.1.3.10.9.28	Effective Date	2015‑11‑15 13:01:18
Status	Draft	Version Label	2.0
Name	TNMGrading	Display Name	TNM Grading
Description Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF) Template for grading tumors in context of UICC/AJCC TNM tumor formula. The allowed values for each tumor site are given by the UICC.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.28
Label	PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Associated with	Associated with 1 concept Id Name Data Set psr-data​element-53  Grading  APSR 2.0
Uses	Uses 3 templates Uses as Name Version 1.3.6.1.4.1.19376.1.8.1.4.2 Containment Author (2.0) 2016‑06‑21 14:02:11 1.3.6.1.4.1.19376.1.8.1.4.6 Containment Informant (2.0) 2016‑07‑08 11:22:58 1.3.6.1.4.1.19376.1.3.10.9.1 Include X Specimen Identified (2.0) 2014‑12‑22 15:54:30
Relationship	Specialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54)
Example	generated example <observation negationInd="false" classCode="OBS" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.3.10.9.28"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="59541-3" codeSystem="2.16.840.1.113883.6.1" displayName="Grade pathology system"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>     <low value="20170712112059"/>  </effectiveTime>  <value code="1" displayName="G1" codeSystem="2.16.840.1.113883.15.6"/>  <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>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 1..* R --> </observation>
Item DT Card Conf Description Label hl7:observation 0 … 1 R PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM   psr-data​element-53  Grading  APSR 2.0 @classCode cs 1 … 1 F OBS @moodCode cs 1 … 1 F EVN @negationInd bl 0 … 1   hl7:templateId II 1 … 1 M PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.10.9.28 hl7:id II 0 … * R PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM hl7:code CE (extensible) 1 … 1 M PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM @code CONF 1 … 1 F 59541-3 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (LOINC) @codeSystemName 1 … 1 F LOINC @displayName 1 … 1 F Grade pathology system hl7:text ED 0 … 1 R PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM hl7:statusCode CS (required) 1 … 1 M The 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. PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM   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 PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM hl7:value CD (extensible) 1 … 1 R PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM   Constraint - if grading system is not to recognize from sender, the value set for a 4 tiered grading has to be chosen. - if grading for German Cancer Registries is intended, only the values from code system 1.2.276.0.76.5.336 in value set 1.3.6.1.4.1.19376.1.3.11.31 SHOULD be used.   CONF The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.31 UICC Grade 4 tiered (2015‑11‑13 19:46:53) or The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.29 UICC Grade 3 tiered (2015‑11‑13 19:36:21) or The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.30 UICC Grade 2 tiered (2015‑11‑13 19:43:09) hl7:author II 0 … * C Author 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 Author (2016‑06‑21 14:02:11) PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM hl7:informant II 0 … * R Informant 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 Informant (2016‑07‑08 11:22:58) PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM Included 1 … * R 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 … * 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-data​element-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 @classCode cs 0 … 1 F SPEC hl7:id II 1 … 1 R Specimen ID, coming from the LIS PaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified   psr-data​element-66  Part 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-95  Parent ID  APSR 2.0 psr-data​element-98  Specimen ID  APSR 2.0

List of all versions of this template

• 2015-11-15 13:01:18 (Under develeopment)