1.3.6.1.4.1.19376.1.8.1.2.5/static-2014-05-13T193126

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Id1.3.6.1.4.1.19376.1.8.1.2.5Effective Date valid from 2014‑05‑13 19:31:26
Status DraftVersion Label2.0
NameDiagnosticConclusionSectionDisplay NameDiagnostic Conclusion Section
Description
The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.5
LabelPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 3 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.8.1.1.1Containment Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.2Include CDA author IHE2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.3.10.4.5Containment CDA Update Information Organizer (2.0)2017‑11‑14 15:22:14
1.3.6.1.4.1.19376.1.8.1.3.6Containment Problem Organizer (2.0)2015‑08‑13 10:24:55
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example
generated example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.5"/>  <code code="22637-3" codeSystem="2.16.840.1.113883.6.1" displayName="'Pathology report diagnosis"/>  <title>DIAGNOSTIC CONCLUSION SECTION</title>  <text/>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->
  <entry>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) 1..* R-->
  </entry>  <entry>
    <!-- template 1.3.6.1.4.1.19376.1.3.10.4.5 'Update Information Organizer' (2017-11-14T15:22:14) 0..1 R -->
  </entry></section>
ItemDTCardConfDescriptionLabel
hl7:section
1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
@classCode
cs1 … 1FDOCSECT
@moodCode
cs1 … 1FEVN
 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
II1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.5
hl7:code
CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
@code
CONF1 … 1F22637-3
@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
@codeSystemName
1 … 1FLOINC
@displayName
1 … 1F'Pathology report diagnosis
hl7:title
ST1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
 CONF
element content shall be "DIAGNOSTIC CONCLUSION SECTION"
hl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.6 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>
Included0 … *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 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
@typeCode
cs1 … 1FAUT
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor></author>
hl7:templateId
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
hl7:time
TS1 … 1MThe 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 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
@classCode
cs0 … 1FASSIGNED
hl7:id
II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:addr
AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:telecom
TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Choice1 … 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 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
Included0 … * from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
The name(s) SHALL be given.
@classCode
0 … 1FPSN
@determiner​Code
0 … 1FINSTANCE
hl7:name
PN0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:assigned​Authoring​Device
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
@classCode
cs0 … 1FDEV
@determiner​Code
cs0 … 1FINSTANCE
hl7:manufacturer​Model​Name
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:softwareName
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:code
CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:represented​Organization
0 … 1PaLM 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>
Included0 … 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 … 1FORG
@determiner​Code
0 … 1FINSTANCE
hl7:id
II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:name
ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:telecom
TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:asOrganizationPartOf
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
@classCode
0 … 1FPART
hl7:id
II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
hl7:statusCode
CS0 … 1PaLM 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_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:wholeOrganization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
@classCode
0 … 1FORG
@determiner​Code
0 … 1FINSTANCE
hl7:id
II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:name
ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:addr
AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
hl7:entry
0 … 1CSource: PaLM Suppl. APSR 2.0-3: 6.2.5.4

Contains 1.3.6.1.4.1.19376.1.3.10.4.5 CDA Update Information Organizer (2017‑11‑14 15:22:14)		PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.3.10.4.5']]]
@typeCode
cs1 … 1FCOMP
@context​Conduction​Ind
bl0 … 1Ftrue
 Constraintif ClinicalDocument.versionNumber > 1
hl7:entry
1 … *MSource: 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. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
where [@typeCode='COMP'] [hl7:organizer [hl7:templateId ​[@root​=​'1.3.6.1.4.1.19376.1.8.1.3.6']]]
@typeCode
cs1 … 1FCOMP
@context​Conduction​Ind
bl0 … 1Ftrue
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