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
Other versions this id:
    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
    Used by / Uses
    Used by 0 transactions and 1 template, Uses 2 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
    1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.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 (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>
    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
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    Treeblank.pngTreetree.png@code
    		CONF1 … 1F22635-7
    Treeblank.pngTreetree.png@codeSystem
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    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
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    		0 … *CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
     
    Target.png
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    psr-data​element-79Kyellow.png Device Kyellow.png APSR 2.0
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    		cs1 … 1FAUT
     Example
    author is a person
    <author typeCode="AUT" contextControlCode="OP">
      <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
        <!-- ... -->
      </assignedAuthor>    </author>
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    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
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    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
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    Target.png
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    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
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    		0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
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    		cs0 … 1FDEV
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    		cs0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
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    		SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
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    		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.
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    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
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    		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
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    		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:standardIndustryClassCode
    		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
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    		CE0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 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 2.0‑3:6.3.5.1 Author
     CONF
    The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC)
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    		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
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    		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:standardIndustryClassCode
    		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
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    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
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