1.3.6.1.4.1.19376.1.8.1.2.1/static-2014-05-13T143808

From pubswiki
Jump to navigation Jump to search
Id1.3.6.1.4.1.19376.1.8.1.2.1Effective Date2014‑05‑13 14:38:08
StatusKyellow.png DraftVersion Label2.0
NameClinicalInformationSectionDisplay NameClinical Information Section
Description
The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, reason for anatomic pathology procedure, clinical laboratory data, information about specimens collected in this case (including target site, performer, specimen type, specimen(s) clinical description, and tumor site in case of a cancer).
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.1
LabelPaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 4 concepts
IdNameData Set
psr-data​element-40Kyellow.png Clinical Information Kyellow.png APSR 2.0
psr-data​element-41Kyellow.png Reason for Referral Kyellow.png APSR 2.0
psr-data​element-42Kyellow.png History of Present Illness Kyellow.png APSR 2.0
psr-data​element-43Kyellow.png Clinical Problem Kyellow.png APSR 2.0
Uses
Uses 5 templates
Uses as NameVersion
1.3.6.1.4.1.19376.1.8.1.3.6ContainmentKyellow.png Problem Organizer (2.0)2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.8.1.4.2IncludeKyellow.png Author (2.0)2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.5.3.1.3.1ContainmentKgreen.png IHE Reason for Referral Section (2014)2016‑09‑26 07:58:18
1.3.6.1.4.1.19376.1.5.3.1.3.4ContainmentKgreen.png IHE History of Present Illness Section (2014)2013‑01‑31
1.3.6.1.4.1.19376.1.5.3.1.3.6ContainmentKgreen.png IHE Active Problems Section (2014)2015‑10‑05 16:02:07
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
Example
generated example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.1"/>  <code code="22636-5" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report relevant history"/>  <title>CLINICAL INFORMATION SECTION</title>  <text/>  <languageCode/>  <entry xsi:type="ANY" typeCode="COMP" contextConductionInd="true">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->
  </entry>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->
  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.1 'IHE Reason for Referral Section' (2016-09-26T07:58:18) -->
  </component>  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.4 'History of Present Illness Section' (2013-01-31T00:00:00)
-->
  </component>  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.6 'IHE Active Problems Section' (2015-10-05T16:02:07) -->
  </component></section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … 1RPaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
 
Target.png
psr-data​element-40Kyellow.png Clinical Information Kyellow.png APSR 2.0
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.png@moodCode
cs0 … 1FEVN
 Constraint

This section SHALL contain a code element populated with these attributes:

@code="22636-5" 

@codeSystem="'2.16.840.1.113883.6.1" 

@displayName=" Pathology report relevant history”  

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 MAY contain a number of elements component/section introducing sub-sections, each of these sub-sections providing a particular type of clinical information.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

Treetree.pnghl7:templateId
II1 … 1RPaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.1
Treetree.pnghl7:code
CE1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
Treeblank.pngTreetree.png@code
CONF1 … 1F22636-5
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 relevant history
Treetree.pnghl7:title
ST1 … 1RThe Clinical Information Section<title> SHALL be present. It is the local translation of the code@displayName PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
 Example<title>CLINICAL INFORMATION</title>
Treetree.pnghl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
 Example<text> Tissue submitted: left breast biopsy and apical axillary tissue </text>
Treetree.pnghl7:language​Code
CS0 … 1PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (2014‑03‑26)
Treetree.pnghl7:entry
ANY0 … *RProblem organizer
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: 6.3.3.1 Clinical information section
Treeblank.pngTreetree.png@typeCode
cs0 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11)
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2
 Constraint

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.


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:component
0 … 1Subsection

Source: PCC TF-2: 6.3.3.1.1
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.1 IHE Reason for Referral Section (2016‑09‑26 07:58:18)		PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
 
Target.png
psr-data​element-41Kyellow.png Reason for Referral Kyellow.png APSR 2.0
Treetree.pnghl7:component
0 … 1Subsection


Source: PCC TF-2: 6.3.3.2.1
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 IHE History of Present Illness Section (2013‑01‑31)		PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
 
Target.png
psr-data​element-42Kyellow.png History of Present Illness Kyellow.png APSR 2.0
Treetree.pnghl7:component
0 … 1Subsection

Source: PCC TF-2: 6.3.3.2.3
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.6 IHE Active Problems Section (2015‑10‑05 16:02:07)		PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
 
Target.png
psr-data​element-43Kyellow.png Clinical Problem Kyellow.png APSR 2.0
Retrieved from "http://pubswiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.8.1.2.1/static-2014-05-13T143808&oldid=2445"