1.3.6.1.4.1.19376.1.8.1.2.1/static-2014-05-13T143808

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Id1.3.6.1.4.1.19376.1.8.1.2.1Effective Date2014‑05‑13 14:38:08
Other versions this id:
    StatusKyellow.png DraftVersion Label2.0
    NameClinicalInformationSectionDisplay NameClinical 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).
    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.1
    LabelPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
    ClassificationCDA Section Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Associated with
    Associated with 4 concepts
    IdNameData Set
    psr-data​element-43Kyellow.png Clinical Problem Kgrey.png APSR 2.0
    psr-data​element-42Kyellow.png History of Present Illness Kgrey.png APSR 2.0
    psr-data​element-40Kyellow.png Clinical Information Kgrey.png APSR 2.0
    psr-data​element-41Kyellow.png Reason for Referral Kgrey.png APSR 2.0
    Used by / Uses
    Used by 0 transactions and 1 template, Uses 5 templates
    Used by as NameVersion
    1.3.6.1.4.1.19376.1.8.1.1.1ContainmentKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
    Uses as NameVersion
    1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
    1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png CDA author IHE2016‑06‑21 14:02:11
    1.3.6.1.4.1.19376.1.5.3.1.3.1ContainmentKgreen.png IHE Reason for Referral Section (2014)2016‑09‑26 07:58:18
    1.3.6.1.4.1.19376.1.5.3.1.3.4ContainmentKgreen.png IHE History of Present Illness Section (2014)2013‑01‑31
    1.3.6.1.4.1.19376.1.5.3.1.3.6ContainmentKgreen.png IHE Active Problems Section (2014)2015‑10‑05 16:02:07
    RelationshipSpecialization: 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>
    ItemDTCardConfDescriptionLabel
    hl7:section
    		0 … 1RPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
     
    Target.png
    psr-data​element-40Kyellow.png Clinical Information Kgrey.png APSR 2.0
    Treetree.png@classCode
    		cs0 … 1FDOCSECT
    Treetree.png@moodCode
    		cs0 … 1FEVN
     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.

    Treetree.pnghl7:templateId
    		II1 … 1RPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.1
    Treetree.pnghl7:code
    		CE1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
    Treeblank.pngTreetree.png@code
    		CONF1 … 1F22636-5
    Treeblank.pngTreetree.png@codeSystem
    		1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
    Treeblank.pngTreetree.png@codeSystemName
    		1 … 1FLOINC
    Treeblank.pngTreetree.png@displayName
    		1 … 1FPathology report relevant history
    Treetree.pnghl7:title
    		ST1 … 1RThe Clinical Information Section<title> SHALL be present. It is the local translation of the code@displayName 
    		PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
     Example<title>CLINICAL INFORMATION</title>
    Treetree.pnghl7:text
    		SD.TEXT1 … 1MPaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
     Example<text> Tissue submitted: left breast biopsy and apical axillary tissue </text>
    Treetree.pnghl7:language​Code
    		CS0 … 1PaLM Suppl. 2.0‑3: 6.3.4.1 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)
    Treetree.pnghl7:entry
    		ANY0 … *RProblem organizer
    Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (2015‑08‑13 10:24:55)    		PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section
    Treeblank.png where [hl7:organizer]
    Treeblank.pngTreetree.png@typeCode
    		cs0 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
    Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11)
    Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2
    Treetree.pnghl7:author
    		0 … *CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
     
    Target.png
    psr-data​element-4Kyellow.png Pathologist Kgrey.png APSR 2.0
    psr-data​element-79Kyellow.png Device Kgrey.png APSR 2.0
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FAUT
     Example
    author is a person
    <author typeCode="AUT" contextControlCode="OP">
      <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
        <!-- ... -->
      </assignedAuthor>    </author>
    Treeblank.pngTreetree.pnghl7:templateId
    		1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
    Treeblank.pngTreetree.pnghl7:time
    		TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreetree.pnghl7:assignedAuthor
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FASSIGNED
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
     
    Target.png
    psr-data​element-18Kyellow.png Address Kgrey.png APSR 2.0
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Choice1 … 1
    The author is either an assigned person or an authoring device.
    Elements to choose from:
    • hl7:assigned​Person
    • hl7:assigned​Authoring​Device
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
     
    Target.png
    psr-data​element-5Kyellow.png Name Kgrey.png APSR 2.0
    Included1 … 1R from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
    The name(s) SHALL be given.
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPSN
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		PN1 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FDEV
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		cs0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
     Example
    represented organization for author as a device
    <representedOrganization classCode="ORG" determinerCode="INSTANCE">
      <name>
        <!-- ... -->
      </name>    </representedOrganization>
    Included0 … 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.
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
    		CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPART
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
    		CS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
     CONF
    The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
    		IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
    		0 … 1PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standardIndustryClassCode
    		CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.6.2 Author
    Treetree.pnghl7:component
    		0 … 1Subsection

    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. 2.0‑3: 6.3.4.1 Clinical information section
    Treeblank.png where [hl7:section [hl7:code [(@code = '42349-1' and @codeSystem = '2.16.840.1.113883.6.1')]]]
     
    Target.png
    psr-data​element-41Kyellow.png Reason for Referral Kgrey.png APSR 2.0
    Treetree.pnghl7:component
    		0 … 1Subsection


    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. 2.0‑3: 6.3.4.1 Clinical information section
    Treeblank.png where [hl7:section [hl7:code [(@code = '10164-2' and @codeSystem = '2.16.840.1.113883.6.1')]]]
     
    Target.png
    psr-data​element-42Kyellow.png History of Present Illness Kgrey.png APSR 2.0
    Treetree.pnghl7:component
    		0 … 1Subsection

    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. 2.0‑3: 6.3.4.1 Clinical information section
    Treeblank.png where [hl7:section [hl7:code [(@code = '11450-4' and @codeSystem = '2.16.840.1.113883.6.1')]]]
     
    Target.png
    psr-data​element-43Kyellow.png Clinical Problem Kgrey.png APSR 2.0
    Retrieved from "http://pubswiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.8.1.2.1/static-2014-05-13T143808&oldid=1565"