Difference between revisions of "1.3.6.1.4.1.19376.1.8.1.1.1/static-2014-05-13T115757"
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<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.1.1</td><th style="width: 20em; text-align: left;">Effective Date</th><td style="text-align: left;">2014‑05‑13 11:57:57<div>Other versions this id:<ul></ul></div></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Draft</td><th style="width: 20em; text-align: left;">Version Label</th><td style="text-align: left;">2.0</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">AnatomicPathologyStructuredReportContentModule</td><th style="width: 20em; text-align: left;">Display Name</th><td style="text-align: left;">Anatomic Pathology Structured Report Content Module</td></tr><td style="text-align: left;" colspan="4"><table class="treetable" id="templateDescTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Description</td></tr><tr><td><div>Anatomic Pathology Structured Report Content Module. <br /> | <table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.3.6.1.4.1.19376.1.8.1.1.1</td><th style="width: 20em; text-align: left;">Effective Date</th><td style="text-align: left;">2014‑05‑13 11:57:57<div>Other versions this id:<ul></ul></div></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Draft</td><th style="width: 20em; text-align: left;">Version Label</th><td style="text-align: left;">2.0</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">AnatomicPathologyStructuredReportContentModule</td><th style="width: 20em; text-align: left;">Display Name</th><td style="text-align: left;">Anatomic Pathology Structured Report Content Module</td></tr><td style="text-align: left;" colspan="4"><table class="treetable" id="templateDescTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Description</td></tr><tr><td><div>Anatomic Pathology Structured Report Content Module. <br /> | ||
<br />This document content module represents the generic set of constraints applied to any structured report for surgical pathology in all fields of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as for Cytopathology. <br /> | <br />This document content module represents the generic set of constraints applied to any structured report for surgical pathology in all fields of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as for Cytopathology. <br /> | ||
− | + | <br />The | |
</span> | </span> | ||
<span style="-webkit-text-stroke-color: rgb(0, 0, 0);">The unique id of the current revision of the report is carried by the </span> | <span style="-webkit-text-stroke-color: rgb(0, 0, 0);">The unique id of the current revision of the report is carried by the </span> | ||
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<div> | <div> | ||
− | + | </div></td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelgreen"><div>Report ID from use case #1</div><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.8.9.1</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">A7102400008_1</span><span class="ppsign">"</span> <span class="ppattribute">assigningAuthorityName</span><span class="ppsign">="</span><span class="ppcontent">IHE PaLM Technical Committee</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span></tt></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:code<br /></strong></tt></td></tr></table></td><td><strong>CE</strong> (required)</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>ClinicalDocument/code SHALL be present. The document type of this content module is always<br /><code code="60568-3"<br />codeSystem="2.16.840.1.113883.6.1"<br />displayName="Pathology Synoptic report"<br />codeSystemName="LOINC"/><br /> | |
− | + | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@code<br /></strong></tt></td></tr></table></td><td rowspan="4" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">60568-3</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@codeSystemName<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">LOINC</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@displayName<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">Pathology Synoptic report</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:title<br /></strong></tt></td></tr></table></td><td><strong>ST</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>The APSR <title> SHALL be present. It is the local translation of the code@displayName.<br /> | |
− | + | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelgreen"><div>Report title from use case #1</div><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">title</span><span class="ppsign">></span><span class="pptext">ANATOMIC PATHOLOGY REPORT - BREAST BIOPSY</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">></span></span></tt></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:effectiveTime<br /></strong></tt></td></tr></table></td><td><strong>TS</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>ClinicalDocument/effectiveTime SHALL be present. It contains the creation date & time of the laboratory report as an electronic document. In case this is a new revision replacing a previous version (identified in parentDocument), this is the date & time of the new revision.<div> | |
</div> | </div> | ||
− | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2. | + | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:confidentialityCode<br /></strong></tt></td></tr></table></td><td><strong>CE</strong> (required)</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>ClinicalDocument/confidentialityCode SHALL be present in accordance with the HL7 CDA R2 standard.<br /> |
− | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2. | + | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 <i>HL7 BasicConfidentialityKind </i>(2014‑06‑09)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:language​Code<br /></strong></tt></td></tr></table></td><td><strong>CS</strong> (required)</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>ClinicalDocument/languageCode SHALL be present in accordance with the HL7 CDA R2 standard.<br /> |
− | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2. | + | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 <i>HumanLanguage </i>(2014‑03‑26)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:setId<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>ClinicalDocument/setId SHALL be present to enable further updates of the clinical document. It is an identifier that is common across all revisions of this AP report.<br /> |
− | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2. | + | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@extension<br /></strong></tt></td></tr></table></td><td>st</td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">psr-data​element-</span>50</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Patient / Case / ">[[File:Kyellow.png|14px]] Accession Number </td><td style="width: 35%; vertical-align: top;">[[File:Kgrey.png|14px]] APSR 2.0 </td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><span style="-webkit-font-kerning: none;">A report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report.<br /> |
− | + | </span>The setId element provides a globally unique identifier that is common across all successive revisions of the report. This identifier is similarly composed of setId@root, which SHALL be an OID, and optionally setId@extension.</td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelgreen"><div>Report set ID from use case #1</div><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.8.9.1</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">A7102400008</span><span class="ppsign">"</span> <span class="ppattribute">assigningAuthorityName</span><span class="ppsign">="</span><span class="ppcontent">IHE PaLM Technical Committee</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span></tt></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:versionNumber<br /></strong></tt></td></tr></table></td><td><strong>INT</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>ClinicalDocument/versionNumber MAY be present. As requested by the CDA standard, it is an integer value used as versioning.<br /> | |
− | + | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@value<br /></strong></tt></td></tr></table></td><td>int</td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4"><span style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-font-kerning: none;">A report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report.<br /> | |
− | + | </span> | |
− | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2. | + | <span style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-font-kerning: none;">The version number of the current revision of the report is a positive integer (1, 2 …) provided in the versionNumber element.</span> |
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− | |||
− | |||
</td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelgreen"><div>Report version number for use case #1</div><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">versionNumber</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span></tt></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Included</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td colspan="2"> from 1.3.6.1.4.1.19376.1.3.3.1.1 <i>Human Patient</i> (2017‑06‑07)<br />The Patient.<br /> | </td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Example</td><td colspan="4" class="explabelgreen"><div>Report version number for use case #1</div><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">versionNumber</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span></tt></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Included</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td colspan="2"> from 1.3.6.1.4.1.19376.1.3.3.1.1 <i>Human Patient</i> (2017‑06‑07)<br />The Patient.<br /> | ||
− | <div | + | <div> |
<br /> | <br /> | ||
</div> | </div> | ||
− | <span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">The anatomic pathology report is related to ONE SINGLE patient. | + | <span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">The anatomic pathology report is related to ONE SINGLE patient.</span> |
− | + | <br /> | |
<ul> | <ul> | ||
− | + | <li> | |
− | <span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">A patient SHALL be identified with at least one unique patientRole/Id. | + | <span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">A patient SHALL be identified with at least one unique patientRole/Id.</span> |
− | + | </li> | |
− | <span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">The patient address and telecom SHALL be provided (or null flavored). | + | <li> |
+ | <span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">The patient address and telecom SHALL be provided (or null flavored).</span> | ||
+ | <br /> | ||
</li> | </li> | ||
− | + | <li> | |
− | <span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">The patient identity SHALL provide AT LEASTthe patient full name, sex and date/time of birth. | + | <span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">The patient identity SHALL provide AT LEASTthe patient full name, sex and date/time of birth.</span> |
− | + | <br /> | |
</li> | </li> | ||
− | + | </ul> | |
− | <ul></ul> | + | <ul></ul></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:recordTarget<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:patientRole<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:addr<br /></strong></tt></td></tr></table></td><td><strong>AD</strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:telecom<br /></strong></tt></td></tr></table></td><td><strong>TEL</strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:patient<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:name<br /></strong></tt></td></tr></table></td><td><strong>PN</strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:administrative​Gender​Code<br /></strong></tt></td></tr></table></td><td><strong>CE</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:birthTime<br /></strong></tt></td></tr></table></td><td><strong>TS</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Included</td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td colspan="2"> from 1.3.6.1.4.1.19376.1.8.1.4.2 <i>Author</i> (2016‑06‑21 14:02:11)<br /><span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);">The Author Content Module represents an author of the report. This element is repeatable. The sub-element </span> <span style="text-align: justify; text-indent: -36px;">author/time</span> <span style="text-align: justify; text-indent: -36px; -webkit-text-stroke-color: rgb(0, 0, 0);"> carries the date/time of the authoring action.</span> |
− | + | <br /> | |
− | |||
<div> | <div> | ||
− | + | <span style="-webkit-font-kerning: none;"> | |
− | + | <br />At least one ClinicalDocument/author SHALL be present with a time in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. The author/time element carries the date&time the AP report was produced. The AP report can be authored by a software system or by a person or by both.<br /> | |
</span> | </span> | ||
</div> | </div> | ||
<br />Source: <span style="color: rgb(51, 51, 51); font-family: sans-serif; font-size: 12px;">PaLM Suppl.APSR 2.0‑3: 6.3.6.2</span> | <br />Source: <span style="color: rgb(51, 51, 51); font-family: sans-serif; font-size: 12px;">PaLM Suppl.APSR 2.0‑3: 6.3.6.2</span> | ||
<br /> | <br /> | ||
− | + | </td | |
</span> | </span> | ||
<br />Source: PaLM Suppl. APSR 2.0-3: 6.3.6.5<br /> | <br />Source: PaLM Suppl. APSR 2.0-3: 6.3.6.5<br /> | ||
− | <br />Contains 1.3.6.1.4.1.19376.1.8.1.4.6 <i> | + | <br />Contains 1.3.6.1.4.1.19376.1.8.1.4.6 <i>Informant</i> (2016‑07‑08 11:22:58)</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Included</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td colspan="2"> from 2.16.840.1.113883.10.12.104 <i>CDA custodian</i> (2005‑09‑07)<br />ClinicalDocument/custodian SHALL be present with an id in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. It represents the organization that is in charge of maintaining the AP report.<br /> |
− | </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:custodian<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2. | + | </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:custodian<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">psr-data​element-</span>38</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Pathologist / ">[[File:Kyellow.png|14px]] Custodian </td><td style="width: 35%; vertical-align: top;">[[File:Kgrey.png|14px]] APSR 2.0 </td></tr></table></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td></td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">CST</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:assignedCustodian<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td></td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">ASSIGNED</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:represented​Custodian​Organization<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td></td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">ORG</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@determiner​Code<br /></strong></tt></td></tr></table></td><td></td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">INSTANCE</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:name<br /></strong></tt></td></tr></table></td><td><strong>ON</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:telecom<br /></strong></tt></td></tr></table></td><td><strong>TEL</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:addr<br /></strong></tt></td></tr></table></td><td><strong>AD</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Included</td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td colspan="2"> from 1.3.6.1.4.1.19376.1.3.3.1.4 <i>XD-LAB Information Recipient</i> (2008‑08‑08)<br /><span style="-webkit-text-stroke-color: rgb(0, 0, 0);">The Intended Recipient Content Module represents a healthcare provider, </span> |
− | |||
<span style="-webkit-text-stroke-color: rgb(0, 0, 0);">other than the ordering physician, expecting to receive a copy of the report. This repeatable element informationRecipient of the CDA header is used to list the intended recipients who were known at the time the report was created and issued.</span> <br /> | <span style="-webkit-text-stroke-color: rgb(0, 0, 0);">other than the ordering physician, expecting to receive a copy of the report. This repeatable element informationRecipient of the CDA header is used to list the intended recipients who were known at the time the report was created and issued.</span> <br /> | ||
− | |||
<br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF-3: 6.3.2.14</span> | <br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF-3: 6.3.2.14</span> | ||
<br /> | <br /> | ||
− | </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:information​Recipient<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2. | + | </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:information​Recipient<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.3.6.1.4.1.19376.1.3.3.1.4</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:intended​Recipient<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:addr<br /></strong></tt></td></tr></table></td><td><strong>AD</strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:telecom<br /></strong></tt></td></tr></table></td><td><strong>TEL</strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:information​Recipient<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Contains 1.3.6.1.4.1.19376.1.3.10.9.18 <i>PlayingEntity or person with Name</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:received​Organization<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Contains 1.3.6.1.4.1.19376.1.3.10.9.13 <i>Organization with Name, Addr, Telecom</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Included</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td colspan="2"> from 1.3.6.1.4.1.19376.1.3.10.2.4 <i>XD-LAB LegalAuthenticator</i> (2016‑07‑05)<br />The Legal authenticator Content Module describes a pathologist having verified the content of the report, using the element legalAuthenticator.<br /> |
− | <br />The report SHALL have one legal Authenticator<p style="margin: 0.5em 0px; line-height: inherit;" | + | <br />The report SHALL have one legal Authenticator.<br /> |
− | + | <br /> | |
+ | <p style="margin: 0.5em 0px; line-height: inherit;">Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PaLM TF-3: 6.3.2.15</span> | ||
<br /> | <br /> | ||
</p> | </p> | ||
− | + | </td>< | |
<br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PAT TF-3: 6.2.6.1<br /> | <br />Source: <span style="text-align: center; -webkit-text-stroke-color: rgb(0, 0, 0);">PAT TF-3: 6.2.6.1<br /> | ||
</span> | </span> | ||
<br /> | <br /> | ||
<br /> | <br /> | ||
− | + | </td></tr><tr style="vertical-align: top; background-color: | |
<span style="-webkit-text-stroke-color: rgb(0, 0, 0);">documentationOf/serviceEvent/performer. <br />In case more than one laboratory contributed to a service, only the primary laboratory is in the CDA header, attached to the serviceEvent element, and the other (secondary) laboratories are described only in the sections of the report that they contributed to, in the body of the report.</span> | <span style="-webkit-text-stroke-color: rgb(0, 0, 0);">documentationOf/serviceEvent/performer. <br />In case more than one laboratory contributed to a service, only the primary laboratory is in the CDA header, attached to the serviceEvent element, and the other (secondary) laboratories are described only in the sections of the report that they contributed to, in the body of the report.</span> | ||
<p style="margin: 0px; line-height: normal; -webkit-text-stroke-color: rgb(0, 0, 0);"> | <p style="margin: 0px; line-height: normal; -webkit-text-stroke-color: rgb(0, 0, 0);"> | ||
Line 114: | Line 117: | ||
<span style="-webkit-font-kerning: none;">Source: PaLM TF3: 6.3.2.19</span> | <span style="-webkit-font-kerning: none;">Source: PaLM TF3: 6.3.2.19</span> | ||
</p> | </p> | ||
− | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2. | + | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@moodCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>ID of the Act, i.e. Accession number</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="4">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">psr-data​element-</span>50</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Patient / Case / ">[[File:Kyellow.png|14px]] Accession Number </td><td style="width: 35%; vertical-align: top;">[[File:Kgrey.png|14px]] APSR 2.0 </td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">psr-data​element-</span>82</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Order / Order ID / ">[[File:Kyellow.png|14px]] Placer group ID </td><td style="width: 35%; vertical-align: top;">[[File:Kgrey.png|14px]] APSR 2.0 </td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">psr-data​element-</span>49</td><td style="vertical-align: top;" title="Anatomic Pathology Structured Report / Procedure / Order / ">[[File:Kyellow.png|14px]] Order ID </td><td style="width: 35%; vertical-align: top;">[[File:Kgrey.png|14px]] APSR 2.0 </td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:code<br /></strong></tt></td></tr></table></td><td><strong>CE</strong> (extensible)</td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>@code shall be "PATREPE"</td></tr><tr style="vertical-align: top;"><td>@codeSystem shall be "2.16.840.1.113883.5.4"</td></tr><tr style="vertical-align: top;"><td>@codeSystemName shall be "HL7 ActCode"</td></tr><tr style="vertical-align: top;"><td>@displayName shall be "pathology report entry task"</td></tr><tr style="vertical-align: top;"><td>or</td></tr><tr style="vertical-align: top;"><td>@code shall be "371528001"</td></tr><tr style="vertical-align: top;"><td>@codeSystem shall be "2.16.840.1.113883.6.96"</td></tr><tr style="vertical-align: top;"><td>@codeSystemName shall be "SCT"</td></tr><tr style="vertical-align: top;"><td>@displayName shall be "Pathology report (record artifact)"</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:effectiveTime<br /></strong></tt></td></tr></table></td><td><strong>IVL_TS</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Use of sub element documentationOf/serviceEvent/effectiveTime to document the time boundaries of events in the document is appropriate.<br /> |
− | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2. | + | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>lab:statusCode<br /></strong></tt></td></tr></table></td><td><strong>CS</strong> (required)</td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>The statusCode below documentationOf/serviceEvent is an extension to the CDA R2 standard, added by PaLM TF-3 to distinguish a preliminary report (statusCode@code="active") from a final report (statusCode@code="completed"). <br />The statusCode sub element is further described in section A.3 of PaLM TF-3. This sub-element is required. When it is not there, the documented Act is assumed to be completed and the report is assumed to be a final report.<br /> |
<div>This extension to the standard is protected by a dedicated namespace associated in the ClinicalDocument element to the prefix lab:</div> | <div>This extension to the standard is protected by a dedicated namespace associated in the ClinicalDocument element to the prefix lab:</div> | ||
<br /> | <br /> | ||
<div><Clinical Document xmlns:lab="urn:oid:1.3.6.1.4.1.19376.1.3.2" … > <br /> | <div><Clinical Document xmlns:lab="urn:oid:1.3.6.1.4.1.19376.1.3.2" … > <br /> | ||
<br />Source: PaLM TF3: 6.3.2.19</div> | <br />Source: PaLM TF3: 6.3.2.19</div> | ||
− | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2. | + | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4">The <span style="-webkit-text-stroke-color: rgb(0, 0, 0);">statusCode@code="completed" is only applicable, if ALL content modules of the Cl</span>inical Document have the <span style="-webkit-text-stroke-color: rgb(0, 0, 0);">statusCode@code="completed", too, or have the statusCode@code="aborted".</span> |
<br /> | <br /> | ||
− | </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.4 <i>ActStatusActiveCompleted </i>(2008‑08‑08)</td></tr></table></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2">[[File:Kred.png|14px]] error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">hl7:serviceEvent/lab:statusCode[@code='completed']</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Message</td><td colspan="2"><span class="pptext">Status code of all Content Modules SHALL be "complete" or "aborted"</span></td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:performer<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Contains 1.3.6.1.4.1.19376.1.3.3.1.7 <i>Laboratory Performer</i> (2008‑08‑08)</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2. | + | </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.4 <i>ActStatusActiveCompleted </i>(2008‑08‑08)</td></tr></table></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2">[[File:Kred.png|14px]] error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">hl7:serviceEvent/lab:statusCode[@code='completed']</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Message</td><td colspan="2"><span class="pptext">Status code of all Content Modules SHALL be "complete" or "aborted"</span></td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:performer<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Contains 1.3.6.1.4.1.19376.1.3.3.1.7 <i>Laboratory Performer</i> (2008‑08‑08)</td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> where <i> [hl7:assignedEntity]</i></td></tr></table></td><td></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:relatedDocument<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td><p>ClinicalDocument/relatedDocument/parentDocument</p> |
− | |||
<p>This element SHALL be present in case of an update replacement of a previous report. In this case relatedDocument@typeCode attribute SHALL be valued "RPLC", the new report replacing the parent one.</p> | <p>This element SHALL be present in case of an update replacement of a previous report. In this case relatedDocument@typeCode attribute SHALL be valued "RPLC", the new report replacing the parent one.</p> | ||
<p> | <p> | ||
Line 144: | Line 146: | ||
<span style="color: inherit; font-family: inherit; font-size: inherit; font-style: inherit; font-variant-caps: inherit; line-height: inherit;"> | <span style="color: inherit; font-family: inherit; font-size: inherit; font-style: inherit; font-variant-caps: inherit; line-height: inherit;"> | ||
<b>Note 3</b>:</span> A final report can also be replaced by a corrective final report. The rules above also apply in this case.</p> | <b>Note 3</b>:</span> A final report can also be replaced by a corrective final report. The rules above also apply in this case.</p> | ||
− | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2. | + | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">RPLC</td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="4"> </td><td colspan="2"><span style="color: rgb(51, 51, 51); font-family: Verdana, Arial, sans-serif; font-size: 12px;">relatedDocument@typeCode attribute SHALL be valued "RPLC"</span> |
− | |||
<br /> | <br /> | ||
− | </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:parentDocument<br /></strong></tt></td></tr></table></td><td><strong>ANY</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2. | + | </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:parentDocument<br /></strong></tt></td></tr></table></td><td><strong>ANY</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>SHALL be equal to ClinicalDocument/ id of the replaced document.<br /> |
− | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2. | + | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:setId<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>SHALL have the same value in the new report as in the replaced report.<br /> |
− | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2. | + | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:versionNumber<br /></strong></tt></td></tr></table></td><td><strong>INT</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>SHALL have the same value as in the replaced report (when provided there).<br /> |
− | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2. | + | </td><td style="background-color: #FFEEEE;"><span title="">PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module</span></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Included</td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;;"><strong>R</strong></span></td><td colspan="2"> from 2.16.840.1.113883.10.12.113 <i>CDA componentOf</i> (2005‑09‑07)<br /><span style="color: rgb(51, 51, 51); font-family: Verdana, Arial, sans-serif; font-size: 12px;">The ClinicalDocument/componentOf/encompassingEncounter element MAY be present.</span> |
− | |||
<br /> | <br /> | ||
<p style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51);">It describes the encounter during which the reported AP observations were ordered. When present the encounter SHALL:</p> | <p style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51);">It describes the encounter during which the reported AP observations were ordered. When present the encounter SHALL:</p> | ||
Line 159: | Line 159: | ||
</ul> | </ul> | ||
<p style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51);">The encounter MAY provide any number of encounter participants (encompassingEncounter/encounterParticipant/assignedEntity). When present, encounter participants SHALL be in accordance with the HL7 CDA R2 standard with a time and further constrained by this specification to require the presence of name, addr and telecom. Additionally, the encounter participant SHALL have a typeCode with one the values selected from the x_EncounterParticipant domain: The encounter MAY precise the patient location during this encounter. This is the healthcare facility in which the patient was located when the reported AP observations were ordered: encompassingEncounter/location/healthCareFacility. This healthcare facility can be represented as a physical place (e.g., room, floor, building, office) or as an organization (e.g., service, department, team) or both: healthCareFacility/location, healthCareFacility/serviceProviderOrganization.</p> | <p style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51);">The encounter MAY provide any number of encounter participants (encompassingEncounter/encounterParticipant/assignedEntity). When present, encounter participants SHALL be in accordance with the HL7 CDA R2 standard with a time and further constrained by this specification to require the presence of name, addr and telecom. Additionally, the encounter participant SHALL have a typeCode with one the values selected from the x_EncounterParticipant domain: The encounter MAY precise the patient location during this encounter. This is the healthcare facility in which the patient was located when the reported AP observations were ordered: encompassingEncounter/location/healthCareFacility. This healthcare facility can be represented as a physical place (e.g., room, floor, building, office) or as an organization (e.g., service, department, team) or both: healthCareFacility/location, healthCareFacility/serviceProviderOrganization.</p> | ||
− | + | < |
Revision as of 15:01, 7 August 2018
Id | 1.3.6.1.4.1.19376.1.8.1.1.1 | Effective Date | 2014‑05‑13 11:57:57 Other versions this id: | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Status | Draft | Version Label | 2.0 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Name | AnatomicPathologyStructuredReportContentModule | Display Name | Anatomic Pathology Structured Report Content Module | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Context | Pathname / | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Label | PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Classification | CDA Document Level Template | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Open/Closed | Open (other than defined elements are allowed) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Relationship | Specialization: template 2.16.840.1.113883.10.12.1 (2005‑09‑07) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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