1.3.6.1.4.1.19376.1.8.1.2.4/static-2014-05-13T142517

Id	1.3.6.1.4.1.19376.1.8.1.2.4	Effective Date	2014‑05‑13 14:25:17 Other versions this id:
Status	Draft	Version Label	2.0
Name	MicroscopySection	Display Name	Microscopic Observation Section
Description The Microscopic Observation section contains optionally the histopathologic findings of the case and of all of the derived specimens. This section should be used to record the results of histochemical and immunohistochemical stains and of image-based molecular methods.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.4
Label	PaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section
Classification	CDA Section Level Template
Open/Closed	Open (other than defined elements are allowed)
Associated with	Associated with 2 concepts Id Name Data Set psr-data​element-16  microscopic observation text  APSR 2.0 psr-data​element-15  Microscopic observation  APSR 2.0
Uses	Uses 2 templates Uses as Name Version 1.3.6.1.4.1.19376.1.8.1.4.2 Include Author (2.0) 2016‑06‑21 14:02:11 1.3.6.1.4.1.19376.1.8.1.3.6 Containment Problem Organizer (2.0) 2015‑08‑13 10:24:55
Relationship	Specialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Example	example from use case #1 <section classCode="DOCSECT">   <templateId root="1.3.6.1.4.1.19376.1.8.1.2.4"/>  <code code="22635-7" displayName="Pathology report microscopic observation" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <title>MICROSCOPIC OBSERVATION SECTION</title>  <!-- Text: Human-readable part -->   <text>      INVASIVE ADENOCARCINOMA OF THE BREAST.    <br/>     HISTOLOGIC TYPE: DUCTAL.    <br/>     NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3.     <list>       <item>TUBULE FORMATION SCORE: 2.</item>      <item>NUCLEAR PLEOMORPHISM SCORE: 2.</item>      <item>MITOTIC RATE SCORE: 1.</item>    </list>     IN-SITU CARCINOMA: EQUIVOCAL.    <br/>    <br/>     BREAST CANCER BIOMARKER STUDIES:     <list>       <item>PARAFFIN BLOCK NUMBER: A1.</item>      <item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8, Allred Percentage Score = 5, Allred Staining Score = 3).</item>      <item>PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED SCORE = 8).</item>      <item>DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.</item>      <item>HER2/NEU IMMUNOHISTOCHEMISTRY: EQUIVOCAL (2+) FOR OVEREXPRESSION OF HER2/NEU ONCOPROTEIN.</item>      <item>HER2/NEU FISH RESULTS: NOT AMPLIFIED.</item>    </list>  </text></section>
Item DT Card Conf Description Label hl7:section 0 … 1 R PaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section   psr-data​element-15  Microscopic observation  APSR 2.0   Constraint This section SHALL contain a code element populated with these attributes: @code="22635-7" @codeSystem="2.16.840.1.113883.6.1" @displayName="Pathology report microscopic observation"  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 SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document. This section does not contain any subsections.  hl7:templateId II 1 … 1 M PaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.2.4 hl7:code CE 1 … 1 M PaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section @code CONF 1 … 1 F 22635-7 @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 microscopic observation hl7:title ST 1 … 1 R The Microscopic Observation Section<title> SHALL be present. It is the local translation of the code@displayName  PaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section   Example <title>MICROSCOPIC OBSERVATION SECTION</title> hl7:text SD.TEXT 1 … 1 M PaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section   psr-data​element-16  microscopic observation text  APSR 2.0   Example example from use case#1 <text>    INVASIVE ADENOCARCINOMA OF THE BREAST.  <br/>   HISTOLOGIC TYPE: DUCTAL.  <br/>   NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3.   <list>     <item>TUBULE FORMATION SCORE: 2.</item>    <item>NUCLEAR PLEOMORPHISM SCORE: 2.</item>    <item>MITOTIC RATE SCORE: 1.</item>  </list>   IN-SITU CARCINOMA: EQUIVOCAL.  <br/>  <br/>   BREAST CANCER BIOMARKER STUDIES:   <list>     <item>PARAFFIN BLOCK NUMBER: A1.</item>    <item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8, Allred Percentage Score = 5, Allred Staining Score = 3).</item>    <item>PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED SCORE = 8).</item>    <item>DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.</item>    <item>HER2/NEU IMMUNOHISTOCHEMISTRY: EQUIVOCAL (2+) FOR OVEREXPRESSION OF HER2/NEU ONCOPROTEIN.</item>    <item>HER2/NEU FISH RESULTS: NOT AMPLIFIED.</item>  </list></text> Included 0 … * C from 1.3.6.1.4.1.19376.1.8.1.4.2 Author (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 2.0‑3:6.3.5.1 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:entry 0 … * R Problem organizer entry 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. 2.1‑3: 6.3.3.4 Microscopic observation section where [hl7:organizer] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true