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Template APSR2 Macroscopic Observation Section 2014‑05‑13 11:57:09

Id	2.16.840.1.113883.3.1937.99.61.5.10.900272	Effective Date	2014‑05‑13 11:57:09
Status	Draft	Version Label
Name	APSR2MacroscopySection	Display Name	APSR2 Macroscopic Observation Section
Description The Macroscopic Observation section contains the description of the specimen(s) received or obtained by the laboratory (specimen type and state), the gross observation, links to gross images, if taken, processing information and tissue disposition (representative sampling and tissue submitted for additional studies or sent to biorepository.
Context	Parent nodes of template element with id 2.16.840.1.113883.3.1937.99.61.5.10.900272
Classification	CDA Section Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 1 transaction and 1 template, Uses 1 template Used by as Name Version 2.16.840.1.113883.3.1937.99.61.5.4.22 Transaction CDA Document APSR2 2014‑11‑16 11:45:10 2.16.840.1.113883.3.1937.99.61.5.10.900273 Include Anatomic Pathology Structured Report 2014‑05‑13 11:57:57 Uses as Name Version 2.16.840.1.113883.3.1937.99.61.5.10.900280 Containment APSR2 AP Observation Entry DYNAMIC
Relationship	Specialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07) ref ad1bbr-
Example	Example <section>   <templateId root="2.16.840.1.113883.10.12.201"/>  <templateId root="2.16.840.1.113883.3.1937.99.61.5.10.900272"/>  <code code="22634-0" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report gross observation"/>  <title>Macroscopic Observation</title>  <text> Part #1 is labeled “left breast biopsy” and is received fresh after frozen section preparation. It consists of a single firm nodule measuring 3cm in circular diameter and 1.5cm in thickness surrounded by adherent fibrofatty tissue. On section a pale gray, slightly mottled appearance is revealed. Numerous sections are submitted for permanent processing. Part #2 is labeled "apical left axillary tissue" and is received fresh. It consists of two amorphous fibrofatty tissue masses without grossly discernible lymph nodes therein. Both pieces are rendered into numerous sections and submitted in their entirety for history. </text></section>
Expand AllCollapse All Item DT Card Conf Description Label hl7:section 0 … 1 R APSRtion hl7:templateId II 1 … 1 R APSRtion @root uid 1 … 1 F 2.16.840.1.113883.10.12.201 hl7:templateId II 1 … 1 M APSRtion @root uid 1 … 1 F 2.16.840.1.113883.3.1937.99.61.5.10.900272 hl7:id II 0 … 1 APSRtion hl7:code CE 1 … 1 R APSRtion   Constraint Only LOINC code allowed @code CONF 0 … 1 F 22634-0 @codeSystem 0 … 1 F 2.16.840.1.113883.6.1 @displayName 0 … 1 F Pathology report gross observation @codeSystemName 0 … 1 F LOINC hl7:title ST 0 … 1 R APSRtion   CONF element content shall be "Macroscopic observation"   Example <title>Macroscopic Observation</title> hl7:text SD.TEXT 0 … 1 R APSRtion   Example <text> Part #1 is labeled “left breast biopsy” and is received fresh after frozen section preparation. It consists of a single firm nodule measuring 3cm in circular diameter and 1.5cm in thickness surrounded by adherent fibrofatty tissue. On section a pale gray, slightly mottled appearance is revealed. Numerous sections are submitted for permanent processing. Part #2 is labeled "apical left axillary tissue" and is received fresh. It consists of two amorphous fibrofatty tissue masses without grossly discernible lymph nodes therein. Both pieces are rendered into numerous sections and submitted in their entirety for history. </text> hl7:entry 0 … * Contains 2.16.840.1.113883.3.1937.99.61.5.10.900280 APSR2 AP Observation Entry (DYNAMIC) APSRtion @typeCode cs 1 … 1 R   CONF The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)