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Id | 1.3.6.1.4.1.19376.1.3.10.4.1 | Effective Date | 2014‑07‑29 16:02:02Other versions this id: - SpecimenProcedureStep as of 2016‑07‑08 13:20:59
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Status | Cancelled | Version Label | 1.0 |
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Name | SpecimenProcedureStep | Display Name | Specimen Procedure Step |
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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 |
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Context | Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.1 |
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Classification | CDA Entry Level Template |
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Open/Closed | Closed (only defined elements are allowed) |
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Uses | Uses 4 templates | Uses | as | Name | Version |
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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 |
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Relationship | Specialization: template 2.16.840.1.113883.10.12.306 CDA Procedure (2005‑09‑07) ref ad1bbr- |
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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> |
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