1.3.6.1.4.1.19376.1.3.10.9.43/static-2016-10-11T102617

Id	1.3.6.1.4.1.19376.1.3.10.9.43	Effective Date	2016‑10‑11 10:26:17 Other versions this id:
Status	Draft	Version Label	2.0
Name	AssessmentScoringItemAPSR2.0	Display Name	Assessment Scoring Item APSR 2.0
Description Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF) Supportive Observation entry template for describing the granular Items for a scoring system, e.g.Elston-Ellis-Score or Gleason Score
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.43
Label	PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 3 templates, Uses 5 templates Used by as Name Version 1.3.6.1.4.1.19376.1.3.10.9.42 Containment Assessment Scoring System APSR 2.0 (2.0) 2016‑10‑10 11:33:36 1.3.6.1.4.1.19376.1.3.10.4.4 Assessment Scales Observation for Scoring Systems (2.0) 2016‑10‑06 13:12:00 1.3.6.1.4.1.19376.1.3.10.4.3 ICD-O-3 Typing and Grading Observation (2.0) 2015‑11‑29 17:03:18 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
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: ER-Allred Percentage Score Item <observation classCode="OBS" moodCode="EVN" negationInd="false">   <templateId root="1.3.6.1.4.1.19376.1.3.10.9.43"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_AllredPercentage"/>  <code code="444644009" displayName="Number fraction of estrogen receptors in neoplasm using immune stain (observable entity)" codeSystem="2.16.840.1.113883.6.96"/>  <statusCode code="completed"/>  <effectiveTime>     <low value="201001041405-0500"/>  </effectiveTime>  <value xsi:type="PQ" value="85" unit="%"/>  <methodCode code="0107" codeSystem="2.16.840.1.113883.5.84" displayName="Microscopy"/>  <performer>     <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->   </performer>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->   </author>  <informant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->   </informant>  <participant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (2016-07-12T18:44:06) -->   </participant>  <specimen typeCode="SPC">     <specimenRole classCode="SPEC">       <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_slide_A1_ER"/>    </specimenRole>  </specimen></observation>
Item DT Card Conf Description Label hl7:observation 0 … * R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales @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: 6.3.5.10 Assessment scales @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.10.9.43 hl7:id II 0 … * R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales hl7:code CE (extensible) 1 … 1 M PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales   CONF shall be drawn from concept domain "<<395527009 | Microscopic specimen observable (observable entity) |"   Example for use case #1, Breast tubule formation <code code="371470008" codeSystem="2.16.840.1.113883.6.96"/> hl7:text ED 0 … 1 R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales 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: 6.3.5.10 Assessment scales   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 0 … 1 R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales hl7:value INT 1 … 1 R Single numerical score item of a scoring system, e.g. "2"  for Breast tubule formation PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales   Example for use case #1 <value value="2"/> hl7:interpretationCode CE (extensible) 0 … 1 R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales   CONF The value of @code should be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26) hl7:referenceRange 0 … 1 R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales @typeCode cs 1 … 1 F REVF hl7:observationRange 0 … 1 R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales @classCode cs 1 … 1 F OBS @moodCode cs 1 … 1 F EVN.CRT hl7:code CD (extensible) 1 … 1 R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.4 (Act Code) hl7:text ED 0 … 1 R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales hl7:effectiveTime TS 0 … 1 R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales hl7:value ANY 1 … 1 R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales hl7:interpretation CD (extensible) 0 … 1 R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales   CONF The value of @code should be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26) hl7:methodCode CE (extensible) 0 … 1 R PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales   CONF The value of @code should be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (2014‑03‑26) hl7:performer II 0 … * 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: 6.3.5.10 Assessment scales where [hl7:assignedEntity] hl7:author II 0 … * C Author Source: PaLM TF Suppl. APSR 2.0-3:  6.3.6.2 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: 6.3.5.10 Assessment scales 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: 6.3.5.10 Assessment scales 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: 6.3.5.10 Assessment scales where [hl7:participantRole] Included 1 … * M 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 … * M 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