Data Set APSR 2.0 - Concept Order

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Name	ID[‑]	Datatype[‑]	Example[‑]	Description[‑]	Source[‑]	Status[‑]	Terminology[‑]	Value Set[‑]	Type[‑]	Parent concept[‑]
Order (Requested procedure)	psr-dataelement-33			A request to perform examination of a specimen or a set of specimens taken from a patient, i.e. to perform procedures. The Order is the focal object of the transactions between Order Filler and Order Placer or Order Result Tracker. An Order may be standalone or belong to an Order Group. The anatomic pathology laboratory may reorganize the orders placed by a clinical unit, especially in cases where an order was received attached to a set of specimens, which will have to be analyzed separately by different pathologists. For this reason the Order Filler may replace, merge, or split orders received from the Order Placer. This process is accomplished through messages of transactions PAT-1 and PAT-2 initiated by the Order Filler. The Order Filler translates the received Orders into Requested Procedure(s), automatically assigns Study Accession Numbers.	IHE-PAT TF1, 1.12 and 2.2	draft	Pathology order (record artifact) (SNOMED Clinical Terms: 721966001)		Group
Clinical Information	psr-dataelement-40			Clinical Information to a case.		draft	Finding / observation / clinical history (navigational concept) (SNOMED Clinical Terms: 362976009)		Group	Order
Clinical Problem	psr-dataelement-43	Text	Dignität?	Clinical Problem for that a pathology investigation has been ordered		draft	Problem list - Reported (Logical Observation Identifier Names and Codes: 11450-4)		Item	Clinical Information
History of Present Illness	psr-dataelement-42	Text	Gewichtsverlust von 10 kg über 6 Monate	History of present illness / complaints		draft	Personal history finding (finding) (SNOMED Clinical Terms: 307294006)		Item	Clinical Information
Reason for Referral	psr-dataelement-41	Text	bitte um histologische Abklärung des tumorverdächtigen Befundes	Reason for Referral		draft	Reason for referral (narrative) (Logical Observation Identifier Names and Codes: 42349-1)		Item	Clinical Information
Generic AP observation	psr-dataelement-117	Code	C50.9 V L	Atomic unit of a Generic AP observation, coded or as measurement value. Each generic observation must have a textual part for human readibility.		draft		AP Observation 2015-11-22T12:20:34 (dynamic / Extensible/CWE)	Item	Clinical Information
Order ID	psr-dataelement-49			Identification of the order, issued by the Ordering Physician (Order Placer). If more than one Order is placed at the same time, those multiple orders are grouped by the Order placer group ID.		draft			Group	Order
Placer group ID	psr-dataelement-82	Identifier		The ID of a laboratory request, that is a set of orders placed together by a ward and/or a physician to one or more laboratories for a patient, to be performed on one or more specimens collected from this patient. Any message exchanged between Order Filler and Order Placer or Order Result Tracker, is carrying zero or one Order Group.	IHE-PAT TF1 1.12	draft			Item	Order ID
Order placer ID	psr-dataelement-81	Identifier	KHXX_ENDO_18.123451	This is the ID the Order Placer sent.		draft			Item	Order ID
Order filler ID	psr-dataelement-83	Identifier	E18-321654	This is the ID of the Order, coming from the Order Placer, issued by the Order Filler in the Lab. If only one specimen is sent, the Order filler ID may be the same as the Case ID (Accession number).	PaLM TF Vol 1, 3.4.	draft			Item	Order ID
Work order (Requested procedure)	psr-dataelement-84			Work order in the Lab, i.e. the process for grossing, embedding, sectioning, and staining, for one specimen (part), issued by the Order filler.	PaLM TF Vol 1, 3.4.	draft			Group	Order ID
Requested Procedure (Imaging Study (RAD), Work order (LAB))	psr-dataelement-90	Code	40923002 \| Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure) \|	In anatomic Pathology, a Requested Procedure (or imaging Study) is identified by its unique Accession Number (see this term in the data set). A Requested Procedure is attached to an Order (and is equivalent to a Work order in LAB). As expressed in DICOM Supplement 122 the concept of accession in Anatomic Pathology has been determined to be sufficiently equivalent to an accession in Radiology so that the existing Accession Number at the Study level may be reused for the same purpose and with essentially the existing definition. A Requested Procedure may involve more than one acquisition modality (e.g. gross imaging, microscopic imaging) and/or more than one specimen, in which cases the Study will include more than one Series.	IHE-PAT TF1 1.12	draft			Item	Work order
Work order ID	psr-dataelement-100	Identifier		This is the ID for the Work Order		draft			Item	Work order
Work order step (Procedure step)	psr-dataelement-101			A single work order step in the Lab, as Specimen work order step for the Lab processors (e.g. immunostainer), issued by the LIS (Automation manager)	PaLM TF Vol 1, 3.4.	draft			Group	Order ID
Procedure Step (Work order step (LAB))	psr-dataelement-89	String		For each Requested Procedure (see this in the dataset), the basic or special techniques involved in the processing of the corresponding specimen(s) may require different devices (automatons, image acquisition modality, etc). Each Requested Procedure may contain one or more Procedure Steps (Work Order and Specimen Work Order Step). A Procedure Step is the smallest unit of work in the workflow that is scheduled (work to do) and/or performed (work done) by a person or a machine (automaton, image acquisition modality, etc) on an object (specimen, tissue sample, tissue section, etc)	IHE-PAT TF1 1.12	draft			Item	Work order step
Work order step ID	psr-dataelement-85	Identifier		This is the ID for a single work order step in the Lab, as Specimen work order step for the Lab processors (e.g. immunostainer), issued by the LIS (Automation manager)	PaLM TF Vol 1, 3.4.	draft			Item	Work order step
Ordering Provider	psr-dataelement-48	Text		Role for a physician or clinician who requests an examination (making an order) on a case sent to a pathology laboratory ("Einsender" in German). When he uses an order entry system, this is issuing the placer order or the placer order group.		draft	Ordering practitioner name (Logical Observation Identifier Names and Codes: 18781-5)		Item	Order
Specimen Collector	psr-dataelement-52	Text		Role for a person who collects a specimen, only in the situation where the specimen was not collected by the ordering physician	IHE_PAT_Suppl_APSR_Rev2 0_TI_2013_10_02	draft			Item	Order