1.3.6.1.4.1.19376.1.3.10.4.3/static-2015-11-29T170318

Id	1.3.6.1.4.1.19376.1.3.10.4.3	Effective Date	2015‑11‑29 17:03:18 Other versions this id:
Status	Draft	Version Label	2.0
Name	ICD-O-3TypingGrading	Display Name	ICD-O-3 Typing and Grading Observation
Description	Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF) Entry template for observation on ICD-O-3 Typing and Grading
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.3
Label	PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3
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-54  Tumor classification (ICD-O-3)  APSR 2.0
Uses	Uses 9 templates Uses as Name Version 1.3.6.1.4.1.19376.1.3.3.1.7 Containment Laboratory Performer (2017) 2008‑08‑08 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 1.3.6.1.4.1.19376.1.8.1.4.7 Containment Additional participant in an entry (2.0) 2016‑07‑12 18:44:06 1.3.6.1.4.1.19376.1.3.10.9.1 Include X Specimen Identified (2.0) 2014‑12‑22 15:54:30 1.3.6.1.4.1.19376.1.3.10.9.38 Containment ICD-O-3 Behavior (2.0) 2015‑12‑03 09:11:54 1.3.6.1.4.1.19376.1.3.10.9.39 Containment ICD-O-3 Differentiation (2.0) 2015‑12‑09 17:12:30 1.3.6.1.4.1.19376.1.3.10.4.4 Containment Assessment Scales Observation for Scoring Systems (2.0) 2016‑10‑06 13:12:00 2.16.840.1.113883.10.12.324 Containment CDA Reference 2005‑09‑07
Relationship	Specialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 (2014‑05‑14 17:09:54)
Example	example for use case #1 <observation classCode="OBS" moodCode="EVN" negationInd="false">   <templateId root="1.3.6.1.4.1.19376.1.3.10.4.3"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_ICDO"/>  <code code="31205-8" codeSystem="2.16.840.1.113883.6.1" displayName="Histology ICD-O-3 Cancer"/>  <statusCode code="completed"/>  <effectiveTime>     <low value="201001041405-0500"/>  </effectiveTime>  <value xsi:type="CD" code="8500/3" codeSystem="2.16.840.1.113883.6.43.1"/>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->   </author>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 1..* R -->   <specimen typeCode="SPC">     <specimenRole classCode="SPEC">       <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_slide_A1_HE"/>    </specimenRole>  </specimen>  <entryRelationship typeCode="SPRT">     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.38 'ICD-O-3 Behavior' (2015-12-03T09:11:54), not used in use case #1 -->   </entryRelationship>  <entryRelationship typeCode="SPRT">     <!-- template 1.3.6.1.4.1.19376.1.3.10.9.39 'ICD-O-3 Differentiation' (2015-12-09T17:12:30) -->   </entryRelationship>  <entryRelationship typeCode="COMP">     <!-- template 1.3.6.1.4.1.19376.1.3.10.4.4 'Assessment Scales Observation for Scoring Systems APSR2' (2016-10-06T13:12:00) -->   </entryRelationship>  <reference>     <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->   </reference></observation>
Item DT Card Conf Description Label hl7:observation 0 … 1 R First four digits of Morphology axis code. A complete code consists of 6 digits (for morphology, behavior and grading), the latter both separated by "/" after the 4th digit in morphology. Behavior and differentiation are coded as sub-observations PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3 @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: 6.3.5.9 ICD‑O‑3 @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.10.4.3 hl7:id II 0 … * R PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3 hl7:code CV (extensible) 1 … 1 M PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3   CONF @code shall be "31205-8" @codeSystem shall be "2.16.840.1.113883.6.1" @codeSystemName shall be "LOINC" @displayName shall be "Histology ICD-O-3 Cancer" or @code shall be "397005006" @codeSystem shall be "2.16.840.1.113883.6.96" @codeSystemName shall be "SNOMED-CT" @displayName shall be "WHO tumor classification (observable entity)" 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: 6.3.5.9 ICD‑O‑3   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: 6.3.5.9 ICD‑O‑3 hl7:value CD 1 … 1 R First four digits of Morphology axis code PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3   psr-data​element-54  Tumor classification (ICD-O-3)  APSR 2.0   CONF The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.33 ICD-O-3 Morphology (2015‑11‑13 14:08:46)   Example for use case #1: invasive breast cancer, NST, well differentiated <value xsi:type="CD" code="8500" codeSystem="2.16.840.1.113883.6.43.1"/> hl7:performer II 0 … 1 C Performing lab Source: PaLM TF-3: 6.3.2.20 Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08) PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3 where [hl7:assignedEntity] hl7:author II 0 … 1 C 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: 6.3.5.9 ICD‑O‑3 where [hl7:author] 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: 6.3.5.9 ICD‑O‑3 hl7:participant II 0 … * R Additional participants Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.6 Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry (2016‑07‑12 18:44:06) PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3 where [hl7:participantRole] 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-95  Parent ID  APSR 2.0 psr-data​element-67  Block ID  APSR 2.0 psr-data​element-66  Part ID  APSR 2.0 psr-data​element-98  Specimen ID  APSR 2.0 psr-data​element-68  Tissue section ID  APSR 2.0 hl7:entryRelationship 1 … 1 R 5th digit in the morphology axis code Contains 1.3.6.1.4.1.19376.1.3.10.9.38 ICD-O-3 Behavior (2015‑12‑03 09:11:54) PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3 where [hl7:observation [hl7:code [(@code = '246463000' and @codeSystem = '2.16.840.1.113883.6.96') or (@code = '31206-6' and @codeSystem = '2.16.840.1.113883.6.1')]]] @typeCode cs 1 … 1 F SPRT hl7:entryRelationship 0 … 1 R 6th digit in the morphology axis code Contains 1.3.6.1.4.1.19376.1.3.10.9.39 ICD-O-3 Differentiation (2015‑12‑09 17:12:30) PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3 where [hl7:observation [hl7:code [(@code = '263522009' and @codeSystem = '2.16.840.1.113883.6.96') or (@code = '21858-6' and @codeSystem = '2.16.840.1.113883.6.1') or @nullFlavor]]] @typeCode cs 1 … 1 F SPRT hl7:entryRelationship 0 … 1 R optional grading by a scoring system, e.g. by means of the Elston-Ellis-Scoring-System in case of invasive breast cancer (ICD-O C50) Contains 1.3.6.1.4.1.19376.1.3.10.4.4 Assessment Scales Observation for Scoring Systems (2016‑10‑06 13:12:00) PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3 where [hl7:observation [hl7:code [(@code = '273249006' and @codeSystem = '2.16.840.1.113883.6.96') or concat(@code, @codeSystem) = doc('include/voc-2.16.840.1.113883.1.11.19918-2014-03-26T000000.xml')//valueSet [1]/conceptList/concept/concat(@code, @codeSystem)]]] @typeCode cs 1 … 1 F COMP hl7:reference 0 … * R Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07) PaLM Suppl. APSR 2.1‑3: 6.3.5.9 ICD‑O‑3