1.3.6.1.4.1.19376.1.3.11.20/static-2015-06-22T154755

Id	1.3.6.1.4.1.19376.1.8.1.4.9	Effective Date	2014‑05‑14 17:09:54
Status	Draft	Version Label	2.0
Name	APObservationEntry	Display Name	AP Observation Entry
Description This content module is usable within a Problem organizer. The “AP Observation” generic template is usable for all AP observations, including ancillary techniques.  An AP observation has a status and an effective time, may describe various participants (persons, devices, organizations), may have a number of additional properties (method, interpretation, text), and may contain embedded images, comments, and sub-observations, which are also AP observations.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.4.9
Label	PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Associated with	Associated with 3 concepts Id Name Data Set psr-data​element-47  ObservationReport  APSR 2.0 psr-data​element-57  Scoring systems  APSR 2.0 psr-data​element-65  Generic AP observation  APSR 2.0
Uses	Uses 10 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 1.3.6.1.4.1.19376.1.8.1.4.9 Containment AP Observation Entry (2.0) 2014‑05‑14 17:09:54 1.3.6.1.4.1.19376.1.8.1.4.10 Containment Embedded Image 2016‑06‑22 16:08:01 2.16.840.1.113883.10.12.307 Containment CDA RegionOfInterest 2005‑09‑07 1.3.6.1.4.1.19376.1.5.3.1.4.2 Containment IHE Comment Entry (2014) 2013‑12‑20 1.3.6.1.4.1.19376.1.3.10.9.1 Include X Specimen Identified (2.0) 2014‑12‑22 15:54:30 2.16.840.1.113883.10.12.324 Containment CDA Reference 2005‑09‑07
Relationship	Specialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07) ref ad1bbr-
Example	Observation example for use case #1, estrogen receptor <observation classCode="OBS" moodCode="EVN" negationInd="false">   <templateId root="1.3.6.1.4.1.19376.1.8.1.4.9"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_ER"/>  <code code="16112-5" codeSystem="2.16.840.1.113883.6.1" displayName="Estrogen receptor [Interpretation] in Tissue"/>  <statusCode code="completed"/>  <effectiveTime>     <low value="201001041405-0500"/>  </effectiveTime>  <value xsi:type="CD" code="416053008" displayName="Estrogen receptor positive tumor (disorder)" codeSystem="2.16.840.1.113883.6.96"/>  <methodCode code="0107" displayName="Microscopy" codeSystem="2.16.840.1.113883.5.84"/>  <performer>     <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'CDA Performer IHE (Body)' (dynamic) -->   </performer>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) -->   </author>  <informant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Body) APSR2' (dynamic) -->   </informant>  <participant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (dynamic) -->   </participant>  <entryRelationship xsi:type="" typeCode="COMP">     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' -->   </entryRelationship>  <entryRelationship xsi:type="" typeCode="COMP">     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' -->   </entryRelationship>  <entryRelationship xsi:type="" typeCode="COMP">     <!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' -->   </entryRelationship>  <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>  <reference>     <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (dynamic) -->   </reference></observation>
Item DT Card Conf Description Label hl7:observation 0 … * R PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation   psr-data​element-47  ObservationReport  APSR 2.0 psr-data​element-57  Scoring systems  APSR 2.0 psr-data​element-65  Generic AP observation  APSR 2.0 @classCode cs 1 … 1 F OBS @moodCode cs 1 … 1 F EVN @negationInd bl 0 … 1   hl7:templateId II 1 … 1 M PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.4.9 hl7:id II 0 … * R PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation hl7:code CE (extensible) 1 … 1 M The Anatomic pathology observation code should be taken from a reference terminology, preferably the LOINC terminology. National terminologies may be used. PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation @code CONF 1 … 1 F each_code_for_observable_entities_or_a_specific_procedure @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (LOINC) @codeSystemName 1 … 1 F LOINC @displayName 1 … 1 F see_above   Example <code code="59847-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Histology and Behavior ICD-O-3"/> hl7:text ED 0 … 1 R Narrative text about the observation PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation 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 valueelement. In other cases the status of the intended observation is “aborted” and the result will never come. PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation   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 Date and time the observation has been made PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation hl7:value ANY 0 … * R Observation values using the appropriate data type. Numeric results use data type PQ, which includes the unit. The result is absent in case of ‘aborted’ observation. PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation   Constraint The default data type, cardinalities and value set for the <value> element are dependant on the type of observation.   CONF The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.11 AP Observation (2015‑11‑22 12:20:34)   Example for observation on tumor type <value code="8500/3" codeSystem="2.16.840.1.113883.6.43.1" codeSystemName="ICD-O-3" displayName="Invasive carcinoma of the breast, no special type"/> hl7:interpretationCode CE (extensible) 0 … 1 R One or more codes interpreting the result, expressed with ObservationInterpretation vocabulary (e.g., H = high, L = low).  This element may be coded with other values than those of the ObservationInterpretation vocabulary, given that the coding strength is CWE (coded with exceptions). PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation   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 TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation   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 … 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 TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation   Constraint The performing laboratory is present at this level only if this particular observation was performed by a (subcontractor) laboratory distinct from the one issuing the rest of the observations in this organizer. 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 TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation 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 TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation 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 TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation hl7:entryRelationship 0 … * R Sub-Observation The result obtained for an observation may lead to an additional AP observation to refine this result. This sub-observation is again an Anatomic Pathology Observation. Source: Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.7 Contains 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54) PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation @typeCode cs 1 … 1 F COMP hl7:entryRelationship 0 … * R Embedded image.  This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest.  Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.8 Contains 1.3.6.1.4.1.19376.1.8.1.4.10 Embedded Image (2016‑06‑22 16:08:01) PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation @typeCode cs 1 … 1 F COMP hl7:entryRelationship 0 … * R Region of Interest Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (2005‑09‑07) PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation @typeCode cs 1 … 1 F COMP   Constraint This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest. In the latter case by an entryRelationship @typeCode="SUBJ" hl7:entryRelationship 0 … * R Annotation comment Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20) PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation @typeCode cs 0 … 1 F COMP 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) Specimen identification   Example Example for specimen referencing <specimen>   <!-- which specimen is used for this observation -->   <specimenRole>     <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="slide_A_1_PR"/>  </specimenRole></specimen> 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-66  Part ID  APSR 2.0 psr-data​element-67  Block ID  APSR 2.0 psr-data​element-68  Tissue section ID  APSR 2.0 psr-data​element-95  Parent ID  APSR 2.0 psr-data​element-98  Specimen ID  APSR 2.0 hl7:reference 0 … * R Reference to an external document, or to external observations, e.g. concerning molecular pathology or  genetic testing report Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07) PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation