1.3.6.1.4.1.19376.1.3.11.41/static-2015-11-18T155517

Id	1.3.6.1.4.1.19376.1.3.10.4.1	Effective Date	2016‑07‑08 13:20:59 Other versions this id: SpecimenProcedureStep as of 2014‑07‑29 16:02:02
Status	Draft	Version Label	2.0
Name	SpecimenProcedureStep	Display Name	Specimen Procedure Step
Description Template CDA Procedure (prototype, directly derived from POCD_RM000040 MIF) for Specimen procedure step in APSR 2. This entry collects all the information of source, method and outcome of a specimen procedure from the collection out of the patient through the final product of a stained histologic section or cytologic smear on a glass slide, or a WSI of such a slide. It reflects the workflow and the probe tracking of a pathology laboratory.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.1
Label	PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Associated with	Associated with 7 concepts Id Name Data Set psr-data​element-101  Work order step  APSR 2.0 psr-data​element-24  Specimen collection  APSR 2.0 psr-data​element-25  Specimen processing  APSR 2.0 psr-data​element-87  Procedure ID  APSR 2.0 psr-data​element-89  Procedure Step  APSR 2.0 psr-data​element-90  Requested Procedure  APSR 2.0 psr-data​element-94  Target Site  APSR 2.0
Uses	Uses 7 templates Uses as Name Version 1.3.6.1.4.1.19376.1.3.10.9.1 Include X Specimen Identified (2.0) 2014‑12‑22 15:54:30 1.3.6.1.4.1.19376.1.3.3.1.7 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 1.3.6.1.4.1.19376.1.3.10.9.44 Containment CDA Participant (Body) Procedure Steps APSR2 (2.0) 2014‑10‑26 17:06:28 1.3.6.1.4.1.19376.1.3.10.9.22 Containment Specimen Container in Procedure Step (2.0) 2016‑07‑29 12:09:33 1.3.6.1.4.1.19376.1.3.1.3 Containment Specimen Received (2017) 2008‑08‑08 2.16.840.1.113883.10.12.324 Containment CDA Reference 2005‑09‑07
Relationship	Adaptation: template 2.16.840.1.113883.10.12.306 CDA Procedure (2005‑09‑07) ref ad1bbr-
Example	example for use case #1, Sectioning and ER-Immuno-Staining <procedure negationInd="false" classCode="PROC" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.3.10.4.1"/>  <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008-P4"/>  <code code="117617002" codeSystem="2.16.840.1.113883.6.96" displayName="Immunohistochemistry procedure (procedure)">     <qualifier>       <name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/>      <value code="23307004" displayName="Estrogen receptor (substance)" codeSystem="2.16.840.1.113883.6.96"/>    </qualifier>  </code>  <statusCode code="completed"/>  <effectiveTime>     <low value="201001030925-0500"/>  </effectiveTime>  <targetSiteCode code="441652008" codeSystem="2.16.840.1.113883.6.96" displayName="Formalin-fixed paraffin-embedded tissue specimen (specimen)"/>  <!-- PARENT SPECIMEN on which the procedure step is performed -->   <specimen typeCode="SPC">     <specimenRole classCode="SPEC">       <!-- Parent specimen ID -->       <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_block_A_1"/>    </specimenRole>  </specimen>  <!-- Specimen processor: the lab technician in this case -->   <performer typeCode="PRF">     <time>       <low value="201001030925-0500"/>    </time>    <modeCode code="PHYSICAL" displayName="physical presence" codeSystem="2.16.840.1.113883.5.1064"/>    <assignedEntity>       <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="member#32"/>      <assignedPerson>         <name>           <given>John</given>          <family>Labtech</family>        </name>      </assignedPerson>    </assignedEntity>  </performer>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->   </author>  <!--Product of the procedure, i.e. specimen -->   <participant typeCode="PRD" contextControlCode="OP">     <time>       <low value="201001030925-0500"/>    </time>    <!-- ID of the specimen produced, coming from the LIS -->     <participantRole classCode="SPEC">       <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_slide_A_1_ER"/>      <code code="P" codeSystem="2.16.840.1.113883.5.111"/>      <playingEntity classCode="ENT" determinerCode="INSTANCE">         <code code="TISS" displayName="Tissue, unspecified" codeSystem="2.16.840.1.113883.5.1060"/>        <quantity value="1"/>        <desc/>      </playingEntity>    </participantRole>  </participant>  <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">     <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.22 'CDA Supply Container APSR2' (2016-07-29T12:09:33) -->   </entryRelationship>  <entryRelationship typeCode="COMP" inversionInd="false" contextConductionInd="true" negationInd="false">     <act classCode="ACT" moodCode="EVN" negationInd="false">       <templateId root="1.3.6.1.4.1.19376.1.3.1.3"/>      <code code="SPRECEIVE" codeSystem="1.3.5.1.4.1.19376.1.5.3.2" displayName="Specimen received" codeSystemName="IHEActCode"/>      <effectiveTime>         <low value="201001030925-0500"/>      </effectiveTime>    </act>  </entryRelationship>  <entryRelationship typeCode="REFR" inversionInd="false" contextConductionInd="true" negationInd="false">     <seperatableInd value="false"/>    <procedure classCode="PROC" moodCode="EVN" negationInd="false">       <!-- ID of the child procedure, coming from LIS -->       <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008-P5"/>    </procedure>  </entryRelationship></procedure>
Item DT Card Conf Description Label hl7:procedure 0 … * R PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps   psr-data​element-101  Work order step  APSR 2.0 psr-data​element-24  Specimen collection  APSR 2.0 psr-data​element-25  Specimen processing  APSR 2.0 psr-data​element-90  Requested Procedure  APSR 2.0 @classCode cs 1 … 1 F PROC @moodCode cs 1 … 1 F EVN hl7:templateId II 1 … 1 R PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.3.10.4.1 hl7:id II 0 … * R Procedure ID, coming from the LIS. May be the target (referenced) ID for the child procedure. PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps   psr-data​element-87  Procedure ID  APSR 2.0 psr-data​element-89  Procedure Step  APSR 2.0 hl7:code CD (extensible) 1 … 1 M Coded procedure PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps   Constraint for specimen collection procedure codes for targetSite 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 The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.10 Specimen Collection and Processing (2016‑05‑31 15:09:59)   Example for use case #1, specimen collection <code code="122548005" codeSystem="2.16.840.1.113883.6.96" displayName="Biopsy of breast (procedure)" codeSystemName="SNOMED-CT"/>   Example for use case #1, grossing & embedding <code code="40923002" codeSystem="2.16.840.1.113883.6.96" displayName="Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)"/>   Example for use case #1, sectioning & immunostaining <code code="117617002" codeSystem="2.16.840.1.113883.6.96" displayName="Immunohistochemistry procedure (procedure)"/> hl7:qualifier CR (extensible) 0 … * C Qualifier for staining or other procedures which don´t have values in the vocabulary used. PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps   Constraint Used only in staining and other procedures without values in SCT or LOINC or DICOM vocabulary, e.g. immune stains   Example for use case #1, grossing & embedding <qualifier>   <name code="246355002" displayName="Supporting structure (attribute)" codeSystem="2.16.840.1.113883.6.96"/>  <value code="702941008" displayName="Paraffin embedding (qualifier value)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/></qualifier>   Example for use case #1, Estrogen receptor staining <qualifier>   <name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/>  <value code="23307004" displayName="Estrogen receptor (substance)" codeSystem="2.16.840.1.113883.6.96"/></qualifier>   Example for use case #1, ISH Her-2-neu staining <qualifier>   <name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/>  <value code="164870" displayName="ONCOGENE ERBB2" codeSystem="2.16.840.1.113883.6.174" codeSystemName="OMIM"/></qualifier> hl7:name CV (extensible) 1 … 1 R PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps @code cs 0 … 1 F 246094008_or_246355002 @codeSystem oid 0 … 1 F 2.16.840.1.113883.6.96 @displayName st 0 … 1 F Component investigated (attribute) or Supporting structure (attribute) hl7:value CD (extensible) 1 … 1 R PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps @nullFlavor cs 1 … 1 R   CONF @code shall be "<<105590001 | Substance (substance) |" @codeSystem shall be "2.16.840.1.113883.6.96" @codeSystemName shall be "SNOMED-CT" @displayName shall be "values from substance axis, e.g. Estrogen receptor" or @code shall be "values from G axis" @codeSystem shall be "2.16.840.1.113883.6.174" @codeSystemName shall be "OMIM" @displayName shall be "values from G axis, e.g. erb-b2" or @code shall be "<<272394005 | Technique (qualifier value) |" @codeSystem shall be "2.16.840.1.113883.6.96" @codeSystemName shall be "SNOMED-CT" @displayName shall be "values from technique axis, e.g. Paraffin embedded (qualifier)" hl7:text ED 0 … 1 R PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps   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 (required) 0 … 1 R PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps   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 R PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps hl7:approachSiteCode CD (extensible) 0 … 1 R Approach site in specimen collection PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps @code CONF 0 … 1 F any_code @codeSystem 0 … 1 F 2.16.840.1.113883.5.1052 (Act Site) @codeSystemName 0 … 1 F any_code @displayName 0 … 1 F ActSite hl7:target​Site​Code CD (extensible) 0 … 1 R Target site in body or relative parent relationship in case of specimen processing PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps   psr-data​element-94  Target Site  APSR 2.0   CONF @code shall be "<<123037004 | Body structure (body structure) |" @codeSystem shall be "2.16.840.1.113883.6.96" @codeSystemName shall be "SCT" @displayName shall be "all children of Body structure (body structure)" or @code shall be "any_code" @codeSystem shall be "2.16.840.1.113883.5.1052" @codeSystemName shall be "ActSite" @displayName shall be "any_code" or The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.9 Procedure Site (2016‑06‑01 18:46:15)   Example for use case #1, specimen collection <targetSiteCode code="110497008" displayName="Lower outer quadrant of right breast (body structure)" codeSystem="2.16.840.1.113883.6.96"/>   Example for use case #1, grossing & embedding <targetSiteCode code="309050000" displayName="Body substance sample" codeSystem="2.16.840.1.113883.6.96"/> hl7:qualifier CR (extensible) 0 … * C optional qualifiers for specifying body structures or / and laterality PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps   Example for use case #1, (optional) specification of body structure for specimen collection <qualifier>   <name code="118169006" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen source topography (attribute)" codeSystemName="SNOMED-CT"/>  <value code="255495000" codeSystem="2.16.840.1.113883.6.96" displayName="Right lower quadrant (qualifier value)" codeSystemName="SNOMED-CT"/></qualifier> hl7:name CV (extensible) 1 … 1 R PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps @displayName st 0 … 1 F Specimen source topography @codeSystem oid 1 … 1 F 2.16.840.1.113883.6.96 @code cs 1 … 1 F 118169006 hl7:value CD (extensible) 0 … * R PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps @code CONF 0 … 1 F <<272099008 @codeSystem 0 … 1 F 2.16.840.1.113883.6.96 (Snomed-CT) @codeSystemName 0 … 1 F SCT @displayName 0 … 1 F all children of Descriptor (qualifier values) e.g. right lower quadrant hl7:methodCode CD (extensible) 0 … * R Identifies the technique used to perform a procedure PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps @codeSystem cs 1 … 1 F 2.16.840.1.113883.5.1065 Included 0 … 1 R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30) Parent specimen with parent ID   Constraint ID element of the parent specimen SHOULD be used only   Example for use case #1, parent specimen ID in grossing & embedding <specimen typeCode="SPC">   <specimenRole classCode="SPEC">     <!-- Parent specimen ID -->     <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008"/>  </specimenRole></specimen> hl7:specimen 0 … 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-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:performer 0 … 1 R Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08) PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps hl7:author 0 … * C Contains 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11) PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps hl7:participant 1 … * M One or more specimen (with additives), which participates as product of the procedure Contains 1.3.6.1.4.1.19376.1.3.10.9.44 CDA Participant (Body) Procedure Steps APSR2 (2014‑10‑26 17:06:28) PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps hl7:entryRelationship 0 … * R Specimen container (manufactured product) Contains 1.3.6.1.4.1.19376.1.3.10.9.22 Specimen Container in Procedure Step (2016‑07‑29 12:09:33) PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true   Constraint for manufactured product classCode = MANU for DrugOrOtherMaterial classCode = MMAT code from MaterialEntityClassType hl7:entryRelationship 0 … 1 R Specimen arrival in Lab Contains 1.3.6.1.4.1.19376.1.3.1.3 Specimen Received (2008‑08‑08) PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true hl7:entryRelationship 0 … * R Referencing mechanism to the ID of the child procedures, giving a lis of child procedure IDs PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps @typeCode cs 1 … 1 F REFR @context​Conduction​Ind bl 0 … 1 F true   Constraint contains only ID(s) of the child procedure(s), which is(are) fully described in dedicated entry(s) further down in the Procedure step section. hl7:procedure 1 … 1 R Child procedure PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps @classCode cs 1 … 1 F PROC @moodCode cs 1 … 1 F EVN hl7:id II 1 … * R ID of the child procedure, coming from the LIS. PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps hl7:reference 0 … * R Reference to an external document, or to external procedures, e.g. concerning molecular pathology or  genetic testing report Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07) PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps