1.3.6.1.4.1.19376.1.8.1.2.1/static-2014-05-13T143808

Id	1.3.6.1.4.1.19376.1.8.1.2.1	Effective Date	2014‑05‑13 14:38:08 Other versions this id:
Status	Draft	Version Label	2.0
Name	ClinicalInformationSection	Display Name	Clinical Information Section
Description The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, reason for anatomic pathology procedure, clinical laboratory data, information about specimens collected in this case (including target site, performer, specimen type, specimen(s) clinical description, and tumor site in case of a cancer).
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.1
Label	PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
Classification	CDA Section Level Template
Open/Closed	Open (other than defined elements are allowed)
Associated with	Associated with 4 concepts Id Name Data Set psr-data​element-43  Clinical Problem  APSR 2.0 psr-data​element-40  Clinical Information  APSR 2.0 psr-data​element-42  History of Present Illness  APSR 2.0 psr-data​element-41  Reason for Referral  APSR 2.0
Uses	Uses 5 templates Uses as Name Version 1.3.6.1.4.1.19376.1.8.1.3.6 Containment Problem Organizer (2.0) 2015‑08‑13 10:24:55 1.3.6.1.4.1.19376.1.8.1.4.2 Include Author (2.0) 2016‑06‑21 14:02:11 1.3.6.1.4.1.19376.1.5.3.1.3.1 Containment IHE Reason for Referral Section (2014) 2016‑09‑26 07:58:18 1.3.6.1.4.1.19376.1.5.3.1.3.4 Containment IHE History of Present Illness Section (2014) 2013‑01‑31 1.3.6.1.4.1.19376.1.5.3.1.3.6 Containment IHE Active Problems Section (2014) 2015‑10‑05 16:02:07
Relationship	Specialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example	generated example <section classCode="DOCSECT" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.8.1.2.1"/>  <code code="22636-5" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report relevant history"/>  <title>CLINICAL INFORMATION SECTION</title>  <text/>  <languageCode/>  <entry xsi:type="ANY" typeCode="COMP" contextConductionInd="true">     <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->   </entry>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->   <component>     <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.1 'IHE Reason for Referral Section' (2016-09-26T07:58:18) -->   </component>  <component>     <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.4 'History of Present Illness Section' (2013-01-31T00:00:00) -->   </component>  <component>     <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.6 'IHE Active Problems Section' (2015-10-05T16:02:07) -->   </component></section>
Item DT Card Conf Description Label hl7:section 0 … 1 R PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section   psr-data​element-40  Clinical Information  APSR 2.0 @classCode cs 0 … 1 F DOCSECT @moodCode cs 0 … 1 F EVN   Constraint This section SHALL contain a code element populated with these attributes: @code="22636-5"  @codeSystem="'2.16.840.1.113883.6.1"  @displayName=" Pathology report relevant history”   This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader. The section SHOULD contain as many Problem Organizer entry elements as there are problems (or groups thereof) to be described. These entries provide the machine-readable data corresponding to the narrative block. This section MAY contain a number of elements component/section introducing sub-sections, each of these sub-sections providing a particular type of clinical information. This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document. hl7:templateId II 1 … 1 R PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.2.1 hl7:code CE 1 … 1 M PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section @code CONF 1 … 1 F 22636-5 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) @codeSystemName 1 … 1 F LOINC @displayName 1 … 1 F Pathology report relevant history hl7:title ST 1 … 1 R The Clinical Information Section<title> SHALL be present. It is the local translation of the code@displayName  PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section   Example <title>CLINICAL INFORMATION</title> hl7:text SD.TEXT 1 … 1 M PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section   Example <text> Tissue submitted: left breast biopsy and apical axillary tissue </text> hl7:language​Code CS 0 … 1 PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (2014‑03‑26) hl7:entry ANY 0 … * R Problem organizer Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (2015‑08‑13 10:24:55) PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section where [hl7:organizer] @typeCode cs 0 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true Included 0 … * C from 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11) Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2 hl7:author 0 … * C PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author   psr-data​element-4  Pathologist  APSR 2.0 psr-data​element-79  Device  APSR 2.0 @typeCode cs 1 … 1 F AUT   Example author is a person <author typeCode="AUT" contextControlCode="OP">   <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">     <!-- ... -->   </assignedAuthor></author> hl7:templateId 1 … 1 M PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.4.2 hl7:time TS 1 … 1 M The authoring time is the date & time that this author contributed to the document. It SHALL be provided. PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:assignedAuthor 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author @classCode cs 0 … 1 F ASSIGNED hl7:id II 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:addr AD 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author   psr-data​element-18  Address  APSR 2.0 hl7:telecom TEL 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author Choice 1 … 1 The author is either an assigned person or an authoring device. Elements to choose from: hl7:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author   psr-data​element-5  Name  APSR 2.0 Included 1 … 1 R from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07) The name(s) SHALL be given. @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 1 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author @classCode cs 0 … 1 F DEV @determiner​Code cs 0 … 1 F INSTANCE hl7:manufacturer​Model​Name SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:softwareName SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:code CE 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:represented​Organization 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author   Example represented organization for author as a device <representedOrganization classCode="ORG" determinerCode="INSTANCE">   <name>     <!-- ... -->   </name></representedOrganization> Included 0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07) The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given. @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:name ON 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:telecom TEL 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:addr AD 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:asOrganizationPartOf 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author @classCode 0 … 1 F PART hl7:id II 0 … * R PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:code CE 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.111 (Role Code) hl7:statusCode CS 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC) hl7:effectiveTime IVL_TS 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:wholeOrganization 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:name ON 0 … * PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:telecom TEL 0 … * PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:addr AD 0 … * PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author hl7:component 0 … 1 Subsection Source: PCC TF-2: 6.3.3.1.1 Contains 1.3.6.1.4.1.19376.1.5.3.1.3.1 IHE Reason for Referral Section (2016‑09‑26 07:58:18) PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section where [hl7:section [hl7:code [(@code = '42349-1' and @codeSystem = '2.16.840.1.113883.6.1')]]]   psr-data​element-41  Reason for Referral  APSR 2.0 hl7:component 0 … 1 Subsection Source: PCC TF-2: 6.3.3.2.1 Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 IHE History of Present Illness Section (2013‑01‑31) PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section where [hl7:section [hl7:code [(@code = '10164-2' and @codeSystem = '2.16.840.1.113883.6.1')]]]   psr-data​element-42  History of Present Illness  APSR 2.0 hl7:component 0 … 1 Subsection Source: PCC TF-2: 6.3.3.2.3 Contains 1.3.6.1.4.1.19376.1.5.3.1.3.6 IHE Active Problems Section (2015‑10‑05 16:02:07) PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section where [hl7:section [hl7:code [(@code = '11450-4' and @codeSystem = '2.16.840.1.113883.6.1')]]]   psr-data​element-43  Clinical Problem  APSR 2.0