Item | DT | Card | Conf | Description | Label |
---|
| | 0 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section |
| Constraint | This section SHALL contain a code element populated with these attributes: @code="22634-0" @codeSystem="2.16.840.1.113883.6.1" @displayName="Pathology report gross observation" This section does not contain any subsection. The 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 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 | M | | PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section |
| | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.8.1.2.3 |
| hl7:code
|
| CE | 1 … 1 | M | | PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section |
| | @code
|
| CONF | 1 … 1 | F | 22634-0 |
| | @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 gross observation |
| hl7:title
|
| ST | 1 … 1 | R | The Macroscopic Observation Section<title> SHALL be present. It is the local translation of the code@displayName
| PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section |
| Example | <title>Macroscopic Observation</title> |
| hl7:text
|
| SD.TEXT | 1 … 1 | M | | PaLM Suppl. 2.0‑3: 6.3.4.3 Macroscopic observation section |
| Example | example for use case #1 <text>A. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)</text> |
Included | 0 … * | C | from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (2016‑06‑21 14:02:11) Author
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2
|
| hl7:author
|
| | 0 … * | C | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | @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 2.0‑3:6.3.6.2 Author |
| 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 2.0‑3:6.3.6.2 Author |
| | hl7:assignedAuthor
|
| | 0 … 1 | C | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| cs | 0 … 1 | F | ASSIGNED |
| II | 1 … * | M | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| AD | 1 … * | M | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| TEL | 1 … * | M | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
Choice | 1 … 1 | | The author is either an assigned person or an authoring device.
Elements to choose from:- hl7:assignedPerson
- hl7:assignedAuthoringDevice
|
| | 0 … 1 | C | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
Included | 1 … 1 | R | from 2.16.840.1.113883.10.12.152 (2005‑09‑07) The name(s) SHALL be given. |
| Include | | Error: Cannot find template "2.16.840.1.113883.10.12.152" (2005-09-07T00:00:00) |
|
| | | | hl7:assignedAuthoringDevice
|
| | 0 … 1 | C | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| cs | 0 … 1 | F | DEV |
| cs | 0 … 1 | F | INSTANCE |
| | | | | hl7:manufacturerModelName
|
| SC | 0 … 1 | R | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| SC | 0 … 1 | R | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| CE | 0 … 1 | R | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| | | hl7:representedOrganization
|
| | 0 … 1 | | | PaLM 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> |
Included | 0 … 1 | | from 2.16.840.1.113883.10.12.151 (2005‑09‑07) The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given. |
| Include | | Error: Cannot find template "2.16.840.1.113883.10.12.151" (2005-09-07T00:00:00) |
|
| hl7:entry
|
| | 0 … * | R | Source: PaLM Suppl. APSR 2.0-3: 6.2.5.2 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: 6.3.4.3 Macroscopic observation section |
| where [hl7:organizer] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | @contextConductionInd
|
| bl | 0 … 1 | F | true |