1.3.6.1.4.1.19376.1.8.1.2.4/static-2014-05-13T142517

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Id1.3.6.1.4.1.19376.1.8.1.2.4Effective Date2014‑05‑13 14:25:17
StatusKyellow.png DraftVersion Label2.0
NameMicroscopySectionDisplay NameMicroscopic 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.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.4
LabelPaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 2 concepts
IdNameData Set
psr-data​element-16Kyellow.png microscopic observation text Kyellow.png APSR 2.0
psr-data​element-15Kyellow.png Microscopic observation Kyellow.png APSR 2.0
Uses
Uses 2 templates
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png Author (2.0)2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
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>
ItemDTCardConfDescriptionLabel
hl7:section
0 … 1RPaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section
 
Target.png
psr-data​element-15Kyellow.png Microscopic observation Kyellow.png 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. 

Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.4
Treetree.pnghl7:code
CE1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section
Treeblank.pngTreetree.png@code
CONF1 … 1F22635-7
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1FPathology report microscopic observation
Treetree.pnghl7:title
ST1 … 1RThe 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>
Treetree.pnghl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section
 
Target.png
psr-data​element-16Kyellow.png microscopic observation text Kyellow.png 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>
Included0 … *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
Treetree.pnghl7:author
0 … *CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
 
Target.png
psr-data​element-4Kyellow.png Pathologist Kyellow.png APSR 2.0
psr-data​element-79Kyellow.png Device Kyellow.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 2.0‑3:6.3.5.1 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 2.0‑3:6.3.5.1 Author
Treeblank.pngTreetree.pnghl7:assignedAuthor
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
 
Target.png
psr-data​element-18Kyellow.png Address Kyellow.png APSR 2.0
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.5.1 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 2.0‑3:6.3.5.1 Author
 
Target.png
psr-data​element-5Kyellow.png Name Kyellow.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 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.5.1 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 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1PaLM 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>
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 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standard​Industry​Class​Code
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:asOrganizationPartOf
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPART
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
 CONF
shall be drawn from concept domain "RoleCode"
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:statusCode
CS0 … 1PaLM 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:wholeOrganization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 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 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON0 … *PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:standard​Industry​Class​Code
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Treetree.pnghl7:entry
0 … *RProblem 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
Treeblank.png where [hl7:organizer]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
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