1.3.6.1.4.1.19376.1.3.10.3.1/static-2016-11-13T142808

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Id1.3.6.1.4.1.19376.1.3.10.3.1Effective Date2016‑11‑13 14:28:08
Other versions this id:
    StatusKyellow.png DraftVersion Label2.0
    NameAdditionalSpecifiedObservationSectionDisplay NameAdditional Specified Observation Section
    Description
    Template CDA Section (prototype, directly derived from POCD_RM000040 MIF)

    The Additional Specified Observation section includes additional pathologic finding(s) and the results of ancillary study(yes) with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken.  Further CDA content section modules as subsections are allowed. 
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.3.1
    LabelPaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section
    ClassificationCDA Section Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Associated with
    Associated with 1 concept
    IdNameData Set
    psr-data​element-96Kyellow.png Additional Specified Observation Kgrey.png APSR 2.0
    Used by / Uses
    Used by 0 transactions and 1 template, Uses 2 templates
    Used by as NameVersion
    1.3.6.1.4.1.19376.1.8.1.1.1ContainmentKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
    Uses as NameVersion
    1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png Author (2.0)2016‑06‑21 14:02:11
    1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
    RelationshipAdaptation: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
    Example
    generated example
    <section classCode="DOCSECT" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.3.10.3.1"/>  <code code="xxxxx-x" codeSystem="2.16.840.1.113883.6.1" displayName="specified observation"/>  <title>ADDITIONAL SPECIFIED OBSERVATION SECTION</title>  <text/>  <author>
        <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016‑06‑21 14:02:11) -->
      </author>      <entry typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->
      </entry>    </section>
    ItemDTCardConfDescriptionLabel
    hl7:section
    		0 … *RPaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section
     
    Target.png
    psr-data​element-96Kyellow.png Additional Specified Observation Kgrey.png APSR 2.0
    Treetree.png@classCode
    		cs0 … 1FDOCSECT
    Treetree.png@moodCode
    		cs0 … 1FEVN
     Constraint

       This section SHALL contain a code element populated with these attributes:

    @code ="xxxxx-x" (specific for the additional specified observation)

    @codeSystem ="2.16.840.1.113883.6.1" 

    @displayName ="Pathology report yyyyy (specific) observation"  

    This section SHALL contain a narrative block, represented by a textelement, which renders the information to the human reader.

    The section SHOULD contain as many Problem Organizer entry elements as there are problems or groups thereof to be described. These entries provide the machine-readable data corresponding to the narrative block.

    This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

    This section MAY contain subsections. 

    Treetree.pnghl7:templateId
    		II1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.3.10.3.1
    Treetree.pnghl7:code
    		CE1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section
     ConstraintThe LOINC code SHALL be chosen according the specified observation type
    Treeblank.pngTreetree.png@code
    		CONF1 … 1Fxxxxx-x
    Treeblank.pngTreetree.png@codeSystem
    		1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
    Treeblank.pngTreetree.png@codeSystemName
    		1 … 1FLOINC
    Treeblank.pngTreetree.png@displayName
    		1 … 1Fspecified observation
    Treetree.pnghl7:title
    		ST1 … 1RPaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section
     Example
    MP observation
    <text>MOLECULAR PATHOLOGY OBSERVATION SECTION</text>
    Treetree.pnghl7:text
    		SD.TEXT1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.5 Addtional specified observation section
    Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11)
    Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2 
    Treetree.pnghl7:author
    		0 … *CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
     
    Target.png
    psr-data​element-4Kyellow.png Pathologist Kgrey.png APSR 2.0
    psr-data​element-79Kyellow.png Device Kgrey.png APSR 2.0
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FAUT
     Example
    author is a person
    <author typeCode="AUT" contextControlCode="OP">
      <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
        <!-- ... -->
      </assignedAuthor>    </author>
    Treeblank.pngTreetree.pnghl7:templateId
    		1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
    Treeblank.pngTreetree.pnghl7:time
    		TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreetree.pnghl7:assignedAuthor
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FASSIGNED
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
     
    Target.png
    psr-data​element-18Kyellow.png Address Kgrey.png APSR 2.0
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.5.1 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
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
     
    Target.png
    psr-data​element-5Kyellow.png Name Kgrey.png APSR 2.0
    Included1 … 1R from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
    The name(s) SHALL be given.
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPSN
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		PN1 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FDEV
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		cs0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
    		0 … 1PaLM 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>
    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.
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
    		CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPART
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
    		CS0 … 1PaLM 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)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    		IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
    		CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
    Treetree.pnghl7:entry
    		0 … *RSource: 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: 6.3.3.5 Addtional specified observation section
    Treeblank.png where [hl7:organizer]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
    Retrieved from "http://pubswiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.3.10.3.1/static-2016-11-13T142808&oldid=1754"