1.3.6.1.4.1.19376.1.8.1.2.5/static-2014-05-13T193126

Id	1.3.6.1.4.1.19376.1.8.1.2.5	Effective Date	2014‑05‑13 19:31:26
Status	Draft	Version Label	2.0
Name	DiagnosticConclusionSection	Display Name	Diagnostic Conclusion Section
Description The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.
Context	Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.5
Label	PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section
Classification	CDA Section Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 1 template, Uses 3 templates Used by as Name Version 1.3.6.1.4.1.19376.1.8.1.1.1 Containment Anatomic Pathology Structured Report Content Module (2.0) 2014‑05‑13 11:57:57 Uses as Name Version 1.3.6.1.4.1.19376.1.8.1.4.2 Include CDA author IHE 2016‑06‑21 14:02:11 1.3.6.1.4.1.19376.1.3.10.4.5 Containment Update Information Organizer (2.0) 2017‑11‑14 15:22:14 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="1.3.6.1.4.1.19376.1.8.1.2.5"/>  <code code="22637-3" displayName="Pathology report final diagnosis" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <title>DIAGNOSTIC CONCLUSION SECTION</title>  <text>     <paragraph> A1. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)</paragraph>     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>     ICD-O-CLASSIFICATION: C50.3 M8500/31    <br/>     IN-SITU CARCINOMA: EQUIVOCAL.    <br/>     BREAST CANCER BIOMARKER STUDIES:     <list>       <item>PARAFFIN BLOCK NUMBER: A1.</item>      <item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8, Percentage stained tumor cells = 85%, 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>  <!-- Start Level 3 for Diagnostic Conclusion-->   <entry>     <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) 1..* R-->   </entry>  <entry>     <!-- template 1.3.6.1.4.1.19376.1.3.10.4.5 'Update Information Organizer' (2017-11-14T15:22:14) 0..1 R -->   </entry></section>
Item DT Card Conf Description Label hl7:section 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section @classCode cs 1 … 1 F DOCSECT @moodCode cs 1 … 1 F EVN   Constraint This section SHALL contain a code element populated with these attributes: @code="22637-3" @codeSystem="2.16.840.1.113883.6.1" @displayName="Pathology report diagnosis"  This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader. The section SHALL contain as many Problem Organizer entry elements as there are problems or groups thereof investigated. Each entry provides machine-readable data. 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: 6.3.4.6 Diagnostic conclusion section @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.8.1.2.5 hl7:code CE 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section @code CONF 1 … 1 F 22637-3 @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 diagnosis hl7:title ST 1 … 1 R The Diagnostic Conclusion Section<title> SHALL be present. It is the local translation of the code@displayName  PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section   Example <hl7:title>Pathology Final Diagnosis</hl7:title> hl7:text SD.TEXT 1 … 1 M PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section   Example example for use case#1 <text>   <paragraph> A1. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY) </paragraph>   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>   ICD-O-CLASSIFICATION: C50.3 M8500/31  <br/>   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, Percentage stained tumor cells = 85%, 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 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 @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 2.0‑3:6.3.6.2 Author hl7:assignedAuthor 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode cs 0 … 1 F ASSIGNED hl7:id II 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 1 … * M PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom 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:assigned​Person hl7:assigned​Authoring​Device hl7:assigned​Person 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 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 2.0‑3:6.3.6.2 Author hl7:assigned​Authoring​Device 0 … 1 C PaLM Suppl.APSR 2.0‑3:6.3.6.2 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 2.0‑3:6.3.6.2 Author hl7:softwareName SC 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:represented​Organization 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 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 2.0‑3:6.3.6.2 Author hl7:name ON 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:asOrganizationPartOf 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F PART hl7:id II 0 … * R PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:code CE 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.111 (Role Code) hl7:statusCode CS 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 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 2.0‑3:6.3.6.2 Author hl7:wholeOrganization 0 … 1 PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author @classCode 0 … 1 F ORG @determiner​Code 0 … 1 F INSTANCE hl7:id II 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:name ON 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:telecom TEL 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:addr AD 0 … * PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:standardIndustryClassCode CE 0 … 1 SHALL be chosen from domain OrganizationIndustryClass PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author hl7:entry 0 … 1 C Source: PaLM Suppl. APSR 2.0-3: 6.2.5.4 Contains 1.3.6.1.4.1.19376.1.3.10.4.5 Update Information Organizer (2017‑11‑14 15:22:14) PaLM Suppl. 2.0‑3: 6.3.4.6 Diagnostic conclusion section where [hl7:organizer] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true   Constraint if ClinicalDocument.versionNumber > 1 hl7:entry 1 … * M 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: 6.3.4.6 Diagnostic conclusion section where [not(@nullFlavor)] [hl7:organizer] @typeCode cs 1 … 1 F COMP @context​Conduction​Ind bl 0 … 1 F true