1.3.6.1.4.1.19376.1.3.10.4.1/static-2014-07-29T160202

Id	1.3.6.1.4.1.19376.1.3.10.4.1	Effective Date	2014‑07‑29 16:02:02 Other versions this id: SpecimenProcedureStep as of 2016‑07‑08 13:20:59
Status	Cancelled	Version Label	1.0
Name	SpecimenProcedureStep	Display Name	Specimen Procedure Step
Description Template CDA Procedure (prototype, directly derived from POCD_RM000040 MIF) All procedures, done on a specimen from collection through all work order steps in APW for identification of the hierarchy of all specimen related IDs
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.1
Classification	CDA Entry Level Template
Open/Closed	Closed (only defined elements are allowed)
Uses	Uses 4 templates Uses as Name Version 2.16.840.1.113883.10.12.322 Containment CDA Specimen DYNAMIC 2.16.840.1.113883.10.12.323 Containment CDA Performer (Body) DYNAMIC 1.3.6.1.4.1.19376.1.3.10.4.2 Containment UICC/AJCC TNM Staging and Grading Observation (2.0) DYNAMIC 1.3.6.1.4.1.19376.1.3.10.4.1 Containment Specimen Procedure Step (2.0) DYNAMIC
Relationship	Specialization: template 2.16.840.1.113883.10.12.306 (2005‑09‑07)
Example	Specimen procedure step entry <procedure classCode="PROC" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.8.1.4.11"/>  <templateId root="1.3.6.1.4.1.19376.1.8.1.4.28"/>  <!-- type of the procedure step, here collection -->   <code code="432550005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Core needle biopsy of breast using ultrasound guidance (procedure)">     <originalText>       <reference value="#A7102400008"/>    </originalText>  </code>  <effectiveTime/>  <!-- Anatomic site -->   <targetSiteCode code="664" codeSystem="1.3.6.1.4.1.19376.1.8.2.1" displayName="Lower outer quadrant" codeSystemName="PATHLEX">     <qualifier>       <name code="272741003" codeSystem="2.16.840.1.113883.6.96" displayName="laterality" codeSystemName="SNOMED-CT"/>      <value code="24028007" codeSystem="2.16.840.1.113883.6.96" displayName="right" codeSystemName="SNOMED-CT"/>    </qualifier>  </targetSiteCode>  <!-- Specimen collector: the surgeon in this case -->   <performer/>  <!-- the specimen collected -->   <participant typeCode="PRD">     <participantRole classCode="SPEC">       <!-- specimen id -->       <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="A7102400008"/>      <playingEntity>         <!-- need a code in PATHLEX for "part obtained from a biopsy -->         <code code="373102004" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen from breast obtained by image guided core biopsy (specimen)" codeSystemName="SNOMED CT"/>      </playingEntity>    </participantRole>  </participant>  <!-- Child procedure step: Production of block A1 -->   <entryRelationship typeCode="COMP">     <procedure classCode="PROC" moodCode="EVN">       <templateId root="1.3.6.1.4.1.19376.1.8.1.4.11"/>      <templateId root="1.3.6.1.4.1.19376.1.8.1.4.28"/>      <!-- type of the procedure step, here sampling a tissue dice from the part for a block -->       <code code="433465004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Sampling of tissue specimen (procedure)">         <originalText>           <reference value="#block_A_1"/>        </originalText>      </code>      <effectiveTime/>      <targetSiteCode code="85756007" codeSystem="2.16.840.1.113883.6.96" displayName="Body tissue structure (body structure)" codeSystemName="SNOMED CT">         <qualifier>           <!-- a series of codes in PATHLEX would help to describe the exact topographic source of the tissue obtained by trimming and sampling -->           <name code="118169006" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen source topography (attribute)" codeSystemName="SNOMED-CT"/>          <value code="255503000" codeSystem="2.16.840.1.113883.6.96" displayName="Entire (qualifier value)" codeSystemName="SNOMED-CT"/>        </qualifier>      </targetSiteCode>      <!-- Specimen preparator: a member staff of the pathology lab -->       <Performer/>      <!-- the specimen produced -->       <participant typeCode="PRD">         <participantRole classCode="SPEC">           <!-- specimen ids -->           <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="block_A_1"/>          <parentId root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="A7102400008"/>          <playingEntity>             <!-- need a code in PATHLEX for "block extracted from a part -->             <code code="441652008" codeSystem="2.16.840.1.113883.6.96" displayName="Formalin-fixed paraffin-embedded tissue specimen (specimen)" codeSystemName="SNOMED CT"/>          </playingEntity>        </participantRole>      </participant>    </procedure>  </entryRelationship></procedure>
Item DT Card Conf Description Label hl7:procedure 0 … * (Spe...tep) @classCode cs 1 … 1 F PROC @moodCode cs 1 … 1 F EVN @negationInd bl 0 … 1   hl7:templateId II 1 … 1 R (Spe...tep) @root uid 1 … 1 F 2.16.840.1.113883.10.12.306 hl7:id II 1 … 1 R (Spe...tep) hl7:code CD 1 … 1 R (Spe...tep)   Constraint for specimen collection procedure codes for targetSite or PathLex or SNOMED CT have to be used, for specimen processing (down step the procedures) SNOMED CT is preferred, DICOM could be used if available   CONF @code shall be "17636008" @codeSystem shall be "2.16.840.1.113883.6.96" @displayName shall be "Specimen collection (procedure)" @codeSystemName shall be "SNOMED CT" or @code shall be "40923002" @codeSystem shall be "2.16.840.1.113883.6.96" @displayName shall be "Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)" @codeSystemName shall be "SNOMED CT" hl7:text ED 0 … 1 (Spe...tep)   Example specimen collection procedure <text>ULTRASOUND GUIDED NEEDLE CORE BIOPSY</text>   Example specimen processing procedure <text>CUTTING A SLIDE FROM A PARAFFIN BLOCK</text> hl7:statusCode CS 0 … 1 (Spe...tep)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC) hl7:effectiveTime IVL_TS 0 … 1 (Spe...tep) hl7:methodCode CE 0 … * (Spe...tep)   CONF @codeSystem shall be "2.16.840.1.113883.5.1065" or The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.10 Specimen Collection and Processing (DYNAMIC) hl7:target​Site​Code CD 0 … * (Spe...tep)   CONF @codeSystem shall be "2.16.840.1.113883.5.1052" or The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.9 Procedure Site (DYNAMIC) hl7:performer 0 … * Contains 2.16.840.1.113883.10.12.322 CDA Specimen (DYNAMIC) (Spe...tep) where [hl7:specimenRole] hl7:author 0 … * Contains 2.16.840.1.113883.10.12.323 CDA Performer (Body) (DYNAMIC) (Spe...tep) where [hl7:assignedEntity] hl7:participant 1 … 1 M Contains 1.3.6.1.4.1.19376.1.3.10.4.2 UICC/AJCC TNM Staging and Grading Observation (DYNAMIC) (Spe...tep) where [hl7:observation [hl7:code [(@code = '21902-2' and @codeSystem = '2.16.840.1.113883.6.1') or (@code = 'tnmStage' and @codeSystem = '1.2.276.0.76.3.1.131.1.5.1')]]]   Example Specimen collected or processed <participant typeCode="PRD">   <participantRole classCode="SPEC">     <!-- specimen ids -->     <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="A7102400008"/>    <playingEntity>       <!-- need a code in PATHLEX for "part obtained from a biopsy -->       <code code="theCode" codeSystem="1.3.6.1.4.1.19376.1.8.2.1" displayName="part collected by biopsy" codeSystemName="PATHLEX"/>    </playingEntity>  </participantRole></participant> hl7:entryRelationship 0 … 2 Contains 1.3.6.1.4.1.19376.1.3.10.4.1 Specimen Procedure Step (DYNAMIC) (Spe...tep) where [hl7:procedure [hl7:code [concat(@code, @codeSystem) = doc('include/voc-1.3.6.1.4.1.19376.1.3.11.10-2016-05-31T150959.xml')//valueSet [1]/conceptList/concept/concat(@code, @codeSystem)]]]