1.3.6.1.4.1.19376.1.3.10.9.43

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Template:Templatenote

Template AssessmentScoringItemAPSR2.0

Description

Template CDA Observation (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF)

Actual version

Id1.3.6.1.4.1.19376.1.3.10.9.43Effective Date2016‑10‑11 10:26:17
StatusKyellow.png DraftVersion Label2.0
NameAssessmentScoringItemAPSR2.0Display NameAssessment Scoring Item APSR 2.0
Description
Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF)

Supportive Observation entry template for describing the granular Items for a scoring system, e.g.Elston-Ellis-Score or Gleason Score
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.43
LabelPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 5 templates
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.7ContainmentKgreen.png Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.8.1.4.2ContainmentKyellow.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
1.3.6.1.4.1.19376.1.3.10.9.1IncludeKyellow.png X Specimen Identified (2.0)2014‑12‑22 15:54:30
RelationshipSpecialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54)
Example
example for use case #1: ER-Allred Percentage Score Item
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.9.43"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_AllredPercentage"/>  <code code="444644009" displayName="Number fraction of estrogen receptors in neoplasm using immune stain (observable entity)" codeSystem="2.16.840.1.113883.6.96"/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="201001041405-0500"/>  </effectiveTime>  <value xsi:type="PQ" value="85" unit="%"/>  <methodCode code="0107" codeSystem="2.16.840.1.113883.5.84" displayName="Microscopy"/>  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->
  </performer>  <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>  <specimen typeCode="SPC">
    <specimenRole classCode="SPEC">
      <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_slide_A1_ER"/>    </specimenRole>  </specimen></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … *RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.9.43
Treetree.pnghl7:id
II0 … *RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
Treetree.pnghl7:code
CE (extensible)1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
 CONF
shall be drawn from concept domain "<<395527009 | Microscopic specimen observable (observable entity) |"
 Example
for use case #1, Breast tubule formation
<code code="371470008" codeSystem="2.16.840.1.113883.6.96"/>
Treetree.pnghl7:text
ED0 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
Treetree.pnghl7:statusCode
CS (required)1 … 1MThe observation statusCode is “ completed ” if the observation was actually performed and has produced a result in the  value  element. In other cases the status of the intended observation is “ aborted ” and the result will never come. 
PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
 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_TS0 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
Treetree.pnghl7:value
INT1 … 1RSingle numerical score item of a scoring system, e.g. "2"  for Breast tubule formationPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
 Example
for use case #1
<value value="2"/>
Treetree.pnghl7:interpretationCode
CE (extensible)0 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)
Treetree.pnghl7:referenceRange
0 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREVF
Treeblank.pngTreetree.pnghl7:observationRange
0 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FOBS
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 … 1FEVN.CRT
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CD (extensible)1 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.5.4 (Act Code)
Treeblank.pngTreeblank.pngTreetree.pnghl7:text
ED0 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
Treeblank.pngTreeblank.pngTreetree.pnghl7:effectiveTime
TS0 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
ANY1 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretation
CD (extensible)0 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)
Treetree.pnghl7:methodCode
CE (extensible)0 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (2014‑03‑26)
Treetree.pnghl7:performer
II0 … *CPerforming lab

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. APSR 2.1‑3: 6.3.5.10 Assessment scales
Treetree.pnghl7:author
II0 … *CAuthor

Source: PaLM TF 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. APSR 2.1‑3: 6.3.5.10 Assessment scales
Treetree.pnghl7:informant
II0 … *RInformant

Source: PaLM TF 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. APSR 2.1‑3: 6.3.5.10 Assessment scales
Treetree.pnghl7:participant
II0 … *RAdditional participants

Source: PaLM TF 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. APSR 2.1‑3: 6.3.5.10 Assessment scales
Included1 … *M from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Treetree.pnghl7:specimen
1 … *MRequired 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-66Kyellow.png Part ID Kyellow.png APSR 2.0
psr-data​element-67Kyellow.png Block ID Kyellow.png APSR 2.0
psr-data​element-68Kyellow.png Tissue section ID Kyellow.png APSR 2.0
psr-data​element-95Kyellow.png Parent ID Kyellow.png APSR 2.0
psr-data​element-98Kyellow.png Specimen ID Kyellow.png APSR 2.0


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