Difference between revisions of "1.3.6.1.4.1.19376.1.8.1.3.6/static-2015-08-13T102455"

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Revision as of 09:52, 9 August 2018

Id1.3.6.1.4.1.19376.1.8.1.3.6Effective Date2015‑08‑13 10:24:55
Other versions this id:
    StatusKyellow.png DraftVersion Label2.0
    NameProblemOrganizerDisplay NameProblem Organizer
    Description
    Template CDA Organizer (prototype, directly derived from POCD_RM000040 MIF)

    The problem organizer groups the various observations performed and assocciated images to investigate on a single problem identified on one or more specimens  


    ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.3.6
    LabelPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    ClassificationCDA Entry Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Associated with
    Associated with 2 concepts
    IdNameData Set
    psr-data​element-39Kyellow.png Problem Organizer Kyellow.png APSR 2.0
    psr-data​element-86Kyellow.png Problem ID Kyellow.png APSR 2.0
    Used by / Uses
    Used by 0 transactions and 7 templates, Uses 11 templates
    Used by as NameVersion
    1.3.6.1.4.1.19376.1.3.10.3.1ContainmentKyellow.png Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
    1.3.6.1.4.1.19376.1.8.1.1.1Link.pngKyellow.png Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
    1.3.6.1.4.1.19376.1.8.1.2.1ContainmentKyellow.png Clinical Information Section (2.0)2014‑05‑13 14:38:08
    1.3.6.1.4.1.19376.1.8.1.2.2ContainmentKyellow.png Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
    1.3.6.1.4.1.19376.1.8.1.2.3ContainmentKyellow.png Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
    1.3.6.1.4.1.19376.1.8.1.2.4ContainmentKyellow.png Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
    1.3.6.1.4.1.19376.1.8.1.2.5ContainmentKyellow.png Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
    Uses as NameVersion
    1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.png Author (2.0)2016‑06‑21 14:02:11
    1.3.6.1.4.1.19376.1.8.1.4.6ContainmentKyellow.png Informant (2.0)2016‑07‑08 11:22:58
    1.3.6.1.4.1.19376.1.8.1.4.7ContainmentKyellow.png Additional participant in an entry (2.0)2016‑07‑12 18:44:06
    1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
    1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified (2.0)2014‑12‑22 15:54:30
    1.3.6.1.4.1.19376.1.8.1.4.9ContainmentKyellow.png AP Observation Entry (2.0)2014‑05‑14 17:09:54
    1.3.6.1.4.1.19376.1.3.1.6ContainmentKgreen.png Laboratory Observation (2017)2008‑08‑08
    1.3.6.1.4.1.19376.1.8.1.4.10ContainmentKyellow.png Embedded Image2016‑06‑22 16:08:01
    2.16.840.1.113883.10.12.307ContainmentKgreen.png CDA RegionOfInterest2005‑09‑07
    1.3.6.1.4.1.19376.1.5.3.1.4.2ContainmentKgreen.png IHE Comment Entry (2014)2013‑12‑20
    2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA Reference2005‑09‑07
    RelationshipSpecialization: template 2.16.840.1.113883.10.12.305 (2005‑09‑07)
    Example
    generated example
    <organizer classCode="BATTERY" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.8.1.3.6"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">
        <qualifier>
          <name code="116677004" codeSystem="2.16.840.1.113883.6.96" displayName=" Associated topography (attribute)"/>      <value nullFlavor="cs" code="all children of "362981000"" codeSystem="2.16.840.1.113883.6.96" displayName="all values from 91723000 (Anatomical structure)"/>    </qualifier>      </code>      <component typeCode="COMP">
        <observation>
          <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">
            <value code="115597007" displayName="Description of specimen character (procedure)" codeSystem="2.16.840.1.113883.6.96"/>      </code>        </observation>      </component>      <statusCode code="completed"/>  <effectiveTime>
        <low value="20170131165954"/>  </effectiveTime>      <author>
        <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->
      </author>      <informant>
        <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->
      </informant>      <participant>
        <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (2016-07-12T18:44:06) -->
      </participant>      <performer>
        <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->
      </performer>      <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 0..* R -->
      <component typeCode="COMP" contextConductionInd="true">
        <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (2016-06-22T16:08:01) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <sequenceNumber value="1"/>    <!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' (2005-09-07T00:00:00) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.4.2 'IHE Comment Entry' (2013-12-20T00:00:00) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (2014-05-14T17:09:54) -->
      </component>      <component typeCode="COMP" contextConductionInd="true">
        <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.3.1.6 'Laboratory Observation' (2008-08-08T00:00:00) -->
      </component>      <reference>
        <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
      </reference>    </organizer>
    Example
    example for use case #1, problem: invasive breast cancer
    <organizer classCode="BATTERY" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.8.1.3.6"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_Problem1"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>  <statusCode code="completed"/>  <effectiveTime>
        <low value="201001041605-0500"/>  </effectiveTime>      <!--The problem is expressed by the result of the observation having the same code as organizer/code-->
      <component>
        <observation classCode="OBS" moodCode="EVN">
          <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>      <value code="C50.9" codeSystem="2.16.840.1.113883.6.3" displayName="Malignant neoplasm of breast, unspecified" codeSystemDisplayName="ICD-10"/>    </observation>      </component>      <component typeCode="COMP" contextConductionInd="true">
        <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (2014-05-14T17:09:54) -->
      </component>      <reference>
        <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
      </reference>    </organizer>
    ItemDTCardConfDescriptionLabel
    hl7:organizer
    		0 … *RProblem organizer groups the observations and images investigating a single problem  related to one or more specimensPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
     
    Target.png
    psr-data​element-39Kyellow.png Problem Organizer Kyellow.png APSR 2.0
    Treetree.png@classCode
    		cs1 … 1FBATTERY
    Treetree.png@moodCode
    		cs1 … 1FEVN
    Treetree.pnghl7:templateId
    		II1 … 1MPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.3.6.1.4.1.19376.1.8.1.3.6
    Treetree.pnghl7:id
    		II0 … *RPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
     
    Target.png
    psr-data​element-86Kyellow.png Problem ID Kyellow.png APSR 2.0
    Treetree.pnghl7:code
    		CD (required)0 … 1RProblem

    		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treeblank.pngTreetree.png@code
    		CONF0 … 1F75326-9
    Treeblank.pngTreetree.png@codeSystem
    		0 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
    Treeblank.pngTreetree.png@codeSystemName
    		0 … 1FLOINC
    Treeblank.pngTreetree.png@displayName
    		0 … 1FProblem
    Treetree.pnghl7:statusCode
    		CS (required)1 … 1MThe status of the organizer is  "completed"  if the battery of observations for this problem has been performed. It is  "aborted"  in case some of the intended observations could not be achieve and have been aborted, and appear as such below the organizer. 
    		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
     Constraint
    @code shall be "completed"
    or
    @code shall be "aborted"

     CONF
    The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (2014‑03‑26)
    Treetree.pnghl7:effectiveTime
    		IVL_TS1 … 1MOrganizer time.
    The period of time (possibly reduced to a point in time) during which the information was collected and assembled. 
    		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treetree.pnghl7:author
    		0 … *CAuthor

    Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2

    Contains 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11)    		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treeblank.png where [hl7:author]
     ConstraintThe author SHALL be present if it is different from the main author of the report. For instance the author could be the ordering physician contributing to the Clinical Information section, inside a report authored by the pathologist.
    Treetree.pnghl7:informant
    		0 … *RInformant

    The informant is an actor (person and organization) who provided some of the clinical information carried by this organizer.


    Source: PaLM Suppl. APSR 2.0-3: 6.3.6.5

    Contains 1.3.6.1.4.1.19376.1.8.1.4.6 Informant (2016‑07‑08 11:22:58)    		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treetree.pnghl7:participant
    		0 … *RTranscriptionist, Device, Responsible, Validator


    Source: PaLM Suppl. APSR 2.0-3: 6.3.6.6

    Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry (2016‑07‑12 18:44:06)    		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treeblank.png where [hl7:participantRole]
     ConstraintparticipationType "ENT", "DEV", "RESP", "AUTHEN"
    Treetree.pnghl7:performer
    		0 … 1CPerforming lab.
    The performing laboratory is present at this level only if this particular problem on this particular specimen was investigated by a (subcontractor) distinct laboratory from the one issuing the consolidated report

    Source:     PaLM TF-3: 6.3.2.20

    Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)    		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treeblank.png where [hl7:assignedEntity]
    Included0 … *R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
    Specimen identification outside an AP observation for differentiating or restituting the problem type

    Source: PaLM Suppl. APSR 2.0-3: 6.3.6.9
    Treetree.pnghl7:specimen
    		0 … *RRequired in XD-LAB when more than one specimen is documented at this level. Always required in APSR.
    		PaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified
     
    Target.png
    psr-data​element-17Kyellow.png Specimen identification Kyellow.png APSR 2.0
    Treeblank.pngTreetree.png@typeCode
    		cs0 … 1FSPC
    Treeblank.pngTreetree.pnghl7:specimenRole
    		1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		cs0 … 1FSPEC
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified
     
    Target.png
    psr-data​element-95Kyellow.png Parent ID Kyellow.png APSR 2.0
    psr-data​element-67Kyellow.png Block ID Kyellow.png APSR 2.0
    psr-data​element-66Kyellow.png Part ID Kyellow.png APSR 2.0
    psr-data​element-98Kyellow.png Specimen ID Kyellow.png APSR 2.0
    psr-data​element-68Kyellow.png Tissue section ID Kyellow.png APSR 2.0
    Treetree.pnghl7:component
    		0 … 1RCoding of the Problem reportedPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.pnghl7:observation
    		0 … 1RPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CD (extensible)1 … 1RPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
    		CONF0 … 1F75326-9
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		0 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
    		0 … 1FLOINC
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
    		0 … 1FProblem
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:qualifier
    		CR0 … *ROptional qualifier for separate problems with identical problem type in one specimen, e.g. a urothelial bladder cancer Invasive cancer) and a prostate cancer (invasive cancer) in one cystoprostatectomy specimen. The anatomic structure is able to differentiate.
    		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
     Example
    Problem in urinary bladder in cystoprostatectomy specimen
    <qualifier>
      <name code="116677004" codeSystem="2.16.840.1.113883.6.96" displayName="Associated topography (attribute)" codeSystemName="SNOMED-CT"/>  <value code="302512001" codeSystem="2.16.840.1.113883.6.96" displayName=" Entire urinary bladder (body structure)" codeSystemName="SNOMED-CT"/></qualifier>
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		CV0 … 1RPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
    		cs1 … 1F116677004
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		oid1 … 1F2.16.840.1.113883.6.96
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
    		st1 … 1F Associated topography (attribute)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:value
    		CD (extensible)0 … *RPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
    		CONF0 … 1F<< 91723000
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		0 … 1F2.16.840.1.113883.6.96 (SNOMED Clinical Terms)
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystemName
    		0 … 1FSNOMED-CT
    Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@displayName
    		0 … 1Fall values from Anatomical structure
    Treeblank.pngTreeblank.pngTreetree.pnghl7:value
    		CE (extensible)0 … 1RCode of the problem reportedPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
     CONF
    @code shall be "any_code"
    @codeSystem shall be "2.16.840.1.113883.6.3"
    @codeSystemName shall be "any_code"
    @displayName shall be "ICD-10"
    or
    The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.7 Problem Type (2016‑07‑11 09:52:19)
    Treetree.pnghl7:component
    		0 … *RAny kind of AP observation, for complex observations, e.g. for TNM, ICD-O-3, or Assessment scales, the appropriate templates may be used.

    Source: PaLM Suppl. APSR 2.0-3: 6.3.6.7

    Contains 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54)    		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treeblank.png where [hl7:observation [hl7:code [(@code = 'each_code_for_observable_entities_or_a_specific_procedure' and @codeSystem = '2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
    Treeblank.pngTreetree.pnghl7:sequenceNumber
    		INT0 … 1PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treetree.pnghl7:component
    		0 … *CLaboratory observation
    Contains 1.3.6.1.4.1.19376.1.3.1.6 Laboratory Observation (2008‑08‑08)    		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treeblank.png where [hl7:observation]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
    Treeblank.pngTreetree.pnghl7:sequenceNumber
    		INT0 … 1PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treetree.pnghl7:component
    		0 … *REmbedded image

    This organizer may carry an image focusing on the problem, either directly embedded or encapsulated within a region of interest.



    Contains 1.3.6.1.4.1.19376.1.8.1.4.10 Embedded Image (2016‑06‑22 16:08:01)    		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treeblank.png where [hl7:observationMedia]
    Treeblank.pngTreetree.png@typeCode
    		cs0 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
     Constraint[@classCode="ROIOVL" and moodCode="EVN"]
    Treeblank.pngTreetree.pnghl7:sequenceNumber
    		INT0 … 1PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treetree.pnghl7:component
    		0 … *RRegion of interest

    This organizer may carry an image focusing on the problem, either directly embedded or encapsulated within a region of interest.

    In the latter case by an entryRelationship @typeCode="SUBJ"



    Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (2005‑09‑07)    		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treeblank.png where [hl7:regionOfInterest [hl7:code [@code = doc('include/voc-2.16.840.1.113883.1.11.16117-DYNAMIC.xml')//valueSet [1]/conceptList/*/@code or @nullFlavor]]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
     Constraint[@classCode="ROIOVL" and moodCode="EVN"]
    Treeblank.pngTreetree.pnghl7:sequenceNumber
    		INT0 … 1PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treetree.pnghl7:component
    		0 … *RGeneral comment on this particular problem 

    Source: PCC TF-2: 6.3.4.6
    Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20)    		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treeblank.png where [hl7:act [hl7:code [(@code = '48767-8' and @codeSystem = '2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCOMP
    Treeblank.pngTreetree.png@context​Conduction​Ind
    		bl0 … 1Ftrue
    Treeblank.pngTreetree.pnghl7:sequenceNumber
    		INT0 … 1PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Treetree.pnghl7:reference
    		0 … *RReference to an external document, or to external organizers, or to external observations, e.g. concerning molecular pathology or  genetic testing report

    Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)    		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
    Retrieved from "http://pubswiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.8.1.3.6/static-2015-08-13T102455&oldid=1868"