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Template Anatomic Pathology Structured Report 2014‑05‑13 11:57:57

Id2.16.840.1.113883.3.1937.99.61.5.10.900273Effective Date2014‑05‑13 11:57:57
Statusdraft DraftVersion Label
NameAPSR2Display NameAnatomic Pathology Structured Report
Description
This Document Content Module defines the base set of constraints that apply to all AP structured report, related to any kind of lesion or diagnostic problem. In other words, this is the generic template for any AP structured report.

The body of this Document Content Module and of all its specialized children, share a common hierarchy of sections and entries depicted by figure 4.1.2.1-1 in Volume 1 IHE_PAT_Suppl_Rev2 0_TI_2013_10_02

ContextPathname //
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 11 concepts
IdNameData Set
vacc-dataelement-20draft de-DE Geschlecht draft Vaccination Certificates Document Datatset
vacc-dataelement-1draft de-DE Patient draft Vaccination Certificates Document Datatset
vacc-dataelement-10draft de-DE Name draft Vaccination Certificates Document Datatset
vacc-dataelement-30draft de-DE Krankenversichertennummer draft Vaccination Certificates Document Datatset
vacc-dataelement-40draft de-DE Krankenkassennummer draft Vaccination Certificates Document Datatset
vacc-dataelement-11draft de-DE Vorname draft Vaccination Certificates Document Datatset
vacc-dataelement-12draft de-DE Nachname draft Vaccination Certificates Document Datatset
vacc-dataelement-110draft de-DE Kontoinhaber draft Vaccination Certificates Document Datatset
vacc-dataelement-111draft Family name draft Vaccination Certificates Document Datatset
vacc-dataelement-112draft Given name draft Vaccination Certificates Document Datatset
vacc-dataelement-2draft de-DE Bank draft Vaccination Certificates Document Datatset
Used by / Uses
Used by 1 transaction and 0 templates, Uses 22 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.61.5.4.22Transactiondraft CDA Document APSR22014‑11‑16 11:45:10
Uses as NameVersion
2.16.840.1.113883.3.1937.99.61.5.10.2001Includeactive CDA recordTargetDYNAMIC
2.16.840.1.113883.3.1937.99.61.5.10.2002Includeactive CDA authorDYNAMIC
2.16.840.1.113883.3.1937.99.61.5.10.2003Includeactive CDA custodianDYNAMIC
2.16.840.1.113883.3.1937.99.61.5.10.900217Includedraft eLab_AuftragsidentifikationDYNAMIC
2.16.840.1.113883.3.1937.99.61.5.10.900218Includedraft eLab_DienstleistungDYNAMIC
2.16.840.1.113883.3.1937.99.61.5.10.900219Includedraft eLab_EinsenderDYNAMIC
2.16.840.1.113883.3.1937.99.61.5.10.900272Includedraft APSR2 Macroscopic Observation SectionDYNAMIC
2.16.840.1.113883.3.1937.99.61.5.10.900274Includedraft APSR2 Microscopic Observation Section2014‑05‑13 14:25:17
2.16.840.1.113883.3.1937.99.61.5.10.900275Includedraft APSR2 Clinical Information Section2014‑05‑13 14:38:08
2.16.840.1.113883.3.1937.99.61.5.10.900277Includedraft APSR2 Intraoperative Observation Section2014‑05‑13 19:29:16
2.16.840.1.113883.3.1937.99.61.5.10.900278Includedraft APSR2 Diagnostic Conclusion Section2014‑05‑13 19:31:26
2.16.840.1.113883.3.1937.99.61.5.10.900279Includedraft APSR2 Procedure Steps Section2014‑05‑13 19:33:12
2.16.840.1.113883.3.1937.99.61.5.10.900303Includedraft APSR2 Specimen SectionDYNAMIC
2.16.840.1.113883.10.12.103Includeactive CDA dataEntererDYNAMIC
2.16.840.1.113883.10.12.105Includeactive CDA informationRecipientDYNAMIC
2.16.840.1.113883.10.12.106Includeactive CDA legalAuthenticatorDYNAMIC
2.16.840.1.113883.10.12.107Includeactive CDA authenticatorDYNAMIC
2.16.840.1.113883.10.12.111Includeactive CDA relatedDocumentDYNAMIC
2.16.840.1.113883.10.12.112Includeactive CDA componentDYNAMIC
2.16.840.1.113883.10.12.113Includeactive CDA componentOfDYNAMIC
2.16.840.1.113883.10.12.114Includeactive CDA AuthorizationDYNAMIC
2.16.840.1.113883.10.12.154Includeactive CDA InformantDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
0 … *APSR2
hl7:templateId
II1 … 1RAPSR2
@root
uid1 … 1F2.16.840.1.113883.10.12.1
hl7:templateId
II1 … 1MAPSR2
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.5.10.900273
hl7:id
II1 … 1RAPSR2
hl7:code
CE1 … 1RAPSR2
@code
CONF0 … 1F11526-1
@codeSystem
0 … 1F2.16.840.1.113883.6.1
@displayName
0 … 1FPathology Study
@codeSystemName
0 … 1FLOINC
hl7:title
ST0 … 1APSR2
 CONF
element content shall be "Anatomic Pathology Structured Report"
hl7:effectiveTime
TS1 … 1RAPSR2
hl7:confidentialityCode
CE1 … 1RAPSR2
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)
Included1 … *R from 2.16.840.1.113883.3.1937.99.61.5.10.2001 CDA recordTarget (DYNAMIC)
hl7:recordTarget
1 … *RCDArdotsrget
 
target
vacc-dataelement-1draft de-DE Patient draft Vaccination Certificates Document Datatset
@typeCode
cs0 … 1FRCT
@contextControlCode
cs0 … 1FOP
hl7:patientRole
1 … 1CDArdotsrget
@classCode
cs0 … 1FPAT
Included1 … 1R from 2.16.840.1.113883.3.1937.99.61.5.10.110 National Patient Identifier (DYNAMIC)
hl7:id
II.NL.BSN1 … 1RNatidotsfier
 
target
vacc-dataelement-20draft de-DE Geschlecht draft Vaccination Certificates Document Datatset
@root
uid1 … 1F2.16.840.1.113883.2.4.6.3
@extension
st1 … 1RBurgerservicenummer (National Patient Identifier)
hl7:patient
1 … 1RCDArdotsrget
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
 Example<patient classCode="PSN" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>  <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>  <birthTime value="19620219"/></patient>
hl7:name
PN1 … *RCDArdotsrget
 
target
vacc-dataelement-10draft de-DE Name draft Vaccination Certificates Document Datatset
hl7:administrativeGenderCode
CE1 … 1RCDArdotsrget
 
target
vacc-dataelement-40draft de-DE Krankenkassennummer draft Vaccination Certificates Document Datatset
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 Administrative Gender (HL7 V3) (DYNAMIC)
hl7:birthTime
TS1 … 1RCDArdotsrget
 
target
vacc-dataelement-30draft de-DE Krankenversichertennummer draft Vaccination Certificates Document Datatset
Included1 … *R from 2.16.840.1.113883.3.1937.99.61.5.10.2002 CDA author (DYNAMIC)
hl7:author
1 … *MCDAauthor
 
target
vacc-dataelement-2draft de-DE Bank draft Vaccination Certificates Document Datatset
@typeCode
cs0 … 1FAUT
hl7:time
TS.DATE.MIN1 … 1MCDAauthor
hl7:assignedAuthor
1 … 1MCDAauthor
@classCode
cs0 … 1FASSIGNED
hl7:id
II1 … 1RCDAauthor
hl7:assignedPerson
0 … 1CDAauthor
Included from 2.16.840.1.113883.3.1937.99.61.5.10.900200 CDA Person Elements (2011‑12‑19)
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
hl7:name
PN1 … 1MCDAPdotsents
 
target
vacc-dataelement-10draft de-DE Name draft Vaccination Certificates Document Datatset
vacc-dataelement-110draft de-DE Kontoinhaber draft Vaccination Certificates Document Datatset
hl7:family
ST1 … 1MCDAPdotsents
 
target
vacc-dataelement-11draft de-DE Vorname draft Vaccination Certificates Document Datatset
vacc-dataelement-111draft Family name draft Vaccination Certificates Document Datatset
hl7:given
ST1 … 1MCDAPdotsents
 
target
vacc-dataelement-12draft de-DE Nachname draft Vaccination Certificates Document Datatset
vacc-dataelement-112draft Given name draft Vaccination Certificates Document Datatset
hl7:representedOrganization
0 … 1CDAauthor
Included from 2.16.840.1.113883.3.1937.99.61.5.10.900201 CDA Organization Elements (DYNAMIC)
@classCode
cs0 … 1FORG
@determinerCode
cs0 … 1FINSTANCE
hl7:id
II0 … *CDAOdotsents
hl7:name
ON1 … 1MCDAOdotsents
hl7:telecom
TEL0 … *CDAOdotsents
hl7:addr
AD0 … 1CDAOdotsents
Included0 … 1 from 2.16.840.1.113883.10.12.103 CDA dataEnterer (DYNAMIC)
hl7:dataEnterer
0 … 1CDAddotserer
@typeCode
cs0 … 1FENT
@contextControlCode
cs0 … 1FOP
hl7:time
TS0 … 1CDAddotserer
hl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAddotserer
Included0 … * from 2.16.840.1.113883.10.12.154 CDA Informant (DYNAMIC)
hl7:informant
0 … *CDAidotsmant
@typeCode
cs0 … 1FINF
@contextControlCode
cs0 … 1FOP
Choice1 … 1Elements to choose from:
hl7:assignedEntity
Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAidotsmant
hl7:relatedEntity
Contains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (DYNAMIC)CDAidotsmant
Included1 … 1R from 2.16.840.1.113883.3.1937.99.61.5.10.2003 CDA custodian (DYNAMIC)
hl7:custodian
1 … 1MCDAcdotsdian
@typeCode
cs0 … 1FCST
hl7:assignedCustodian
1 … 1MCDAcdotsdian
@classCode
cs0 … 1FASSIGNED
hl7:representedCustodianOrganization
0 … 1CDAcdotsdian
Included from 2.16.840.1.113883.3.1937.99.61.5.10.900201 CDA Organization Elements (DYNAMIC)
@classCode
cs0 … 1FORG
@determinerCode
cs0 … 1FINSTANCE
hl7:id
II0 … *CDAOdotsents
hl7:name
ON1 … 1MCDAOdotsents
hl7:telecom
TEL0 … *CDAOdotsents
hl7:addr
AD0 … 1CDAOdotsents
Included0 … * from 2.16.840.1.113883.10.12.105 CDA informationRecipient (DYNAMIC)
hl7:informationRecipient
0 … *CDAidotsient
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19366 x_InformationRecipient (DYNAMIC)
hl7:intendedRecipient
1 … 1CDAidotsient
@classCode
cs1 … 1R
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.16772 x_InformationRecipientRole (DYNAMIC)
hl7:id
II0 … *RCDAidotsient
hl7:addr
AD0 … *CDAidotsient
hl7:telecom
TEL0 … *CDAidotsient
hl7:informationRecipient
0 … 1Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)CDAidotsient
hl7:receivedOrganization
0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)CDAidotsient
Included0 … 1 from 2.16.840.1.113883.10.12.106 CDA legalAuthenticator (DYNAMIC)
hl7:legalAuthenticator
0 … 1CDAldotsator
@typeCode
cs0 … 1FLA
@contextControlCode
cs0 … 1FOP
hl7:time
TS1 … 1RCDAldotsator
hl7:signatureCode
CS1 … 1RCDAldotsator
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)
hl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAldotsator
Included0 … * from 2.16.840.1.113883.10.12.107 CDA authenticator (DYNAMIC)
hl7:authenticator
0 … *CDAadotsator
@typeCode
cs0 … 1FAUTHEN
hl7:time
TS1 … 1RCDAadotsator
hl7:signatureCode
CS1 … 1RCDAadotsator
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMIC)
hl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAadotsator
Included0 … * from 2.16.840.1.113883.3.1937.99.61.5.10.900219 eLab_Einsender (DYNAMIC)
hl7:participant
0 … *M

noticeWarning: If isMandatory=true, minimumMultiplicity shall be greater than 0.

CDApdotspant
@typeCode
cs1 … 1FREF
@contextControlCode
cs1 … 1FOP
 Example<!-- ordering provider -->
<participant typeCode="REF">
  <templateId root="1.3.6.1.4.1.19376.1.3.3.1.6"/>  <time>
    <low value="20071104055700.0000-0500"/>    <high value="20071104131600.0000-0500"/>  </time>  <associatedEntity classCode="PROV">
    <id extension="90573" root="1.3.6.1.4.1.19376.1.3.4"/>    <addr nullFlavor="UNK"/>    <telecom nullFlavor="UNK"/>    <associatedPerson>
      <name>
        <family>Patel</family>        <given>Kiran</given>        <prefix>Dr.</prefix>      </name>    </associatedPerson>    <scopingOrganization>
      <id extension="rm83747" root="1.3.6.1.4.1.19376.1.3.4"/>      <name>Hospital</name>      <telecom nullFlavor="UNK"/>      <addr nullFlavor="UNK"/>    </scopingOrganization>  </associatedEntity></participant>
hl7:time
IVL_TS1 … 1RAuftragsdatum

Das Auftragsdatum ist das Datum / Zeit an dem der Auftrag von Auftraggeber abgesendet wird. Das Auftragsdatum wird als time-Element beim Auftraggeber ausgeführt und ist verpflichtend anzugeben. Bei einer manuellen Erfassung eines Auftrags im Labor kann dieses als nullFlavor=“NA“ ausgeführt werden.		CDApdotspant
hl7:associatedEntity
1 … 1MCDApdotspant
@classCode
cs1 … 1FPROV
hl7:id
II1 … 1MIdentifier des AuftraggebersCDApdotspant
hl7:addr
AD1 … *RAdresse des AuftraggebersCDApdotspant
hl7:telecom
TEL1 … 1MBeliebig viele Kontaktdaten des Beteiligten.CDApdotspant
hl7:associatedPerson
0 … 1Name des AuftraggeberCDApdotspant
hl7:scopingOrganization
0 … 1Organisation des Auftraggebers.CDApdotspant
Included0 … * from 2.16.840.1.113883.3.1937.99.61.5.10.900217 eLab_Auftragsidentifikation (DYNAMIC)
hl7:inFulfillmentOf
0 … *CDAidotsntOf
@typeCode
cs1 … 1FFLFS
 Example<!-- order / Zuweisung und Ordermanagement-->
<inFulfillmentOf typeCode="FLFS">
  <order classCode="ACT" moodCode="RQO">
    <id extension="081201-023" root="2.16.840.1.113883.2.16.1.99.3.1"/>  </order></inFulfillmentOf>
hl7:order
1 … 1MAuftragCDAidotsntOf
@classCode
cs1 … 1FACT
@moodCode
cs1 … 1FRQO
hl7:id
II1 … 1M

CDAidotsntOf
Included0 … * from 2.16.840.1.113883.3.1937.99.61.5.10.900218 eLab_Dienstleistung (DYNAMIC)
hl7:documentationOf
0 … *RCDAddotsonOf
@typeCode
cs1 … 1FDOC
 Example<documentationOf typeCode="DOC">
  <serviceEvent>
    <code code="18725-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Microbiolgy Studies"/>    <effectiveTime>
      <low value="20081201061325+0100"/>      <high value="20081201161500+0100"/>    </effectiveTime>  </serviceEvent></documentationOf>
hl7:serviceEvent
1 … 1RCDAddotsonOf
@classCode
cs1 … 1FACT
@moodCode
cs1 … 1FEVN
hl7:code
CE1 … 1MCDAddotsonOf
@code
CONF1 … 1F18725-2
@codeSystem
1 … 1F2.16.840.1.113883.6.1
@displayName
1 … 1FMicrobiology Studies
hl7:effectiveTime
IVL_TS1 … 1Mde-DE Erbringungszeitraum der LeistungCDAddotsonOf
Included0 … * from 2.16.840.1.113883.10.12.111 CDA relatedDocument (DYNAMIC)
hl7:relatedDocument
0 … *CDArdotsment
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.11610 x_ActRelationshipDocument (DYNAMIC)
hl7:parentDocument
1 … 1CDArdotsment
@classCode
cs0 … 1FDOCCLIN
@moodCode
cs0 … 1FEVN
hl7:id
II1 … *RCDArdotsment
hl7:code
CD0 … 1CDArdotsment
@codeSystem
CONF0 … 1F2.16.840.1.113883.6.1
hl7:text
ED0 … 1CDArdotsment
hl7:setId
II0 … 1CDArdotsment
hl7:versionNumber
INT0 … 1CDArdotsment
Included0 … * from 2.16.840.1.113883.10.12.114 CDA Authorization (DYNAMIC)
hl7:authorization
0 … *CDAadotstion
@typeCode
cs0 … 1FAUTH
hl7:consent
1 … 1CDAadotstion
@classCode
cs0 … 1FCONS
@moodCode
cs0 … 1FEVN
hl7:id
II0 … *CDAadotstion
hl7:code
CE0 … 1CDAadotstion
 CONF
shall be drawn from concept domain "ActCode"
hl7:statusCode
CS1 … 1RCDAadotstion
@code
CONF0 … 1Fcompleted
Included1 … 1R from 2.16.840.1.113883.10.12.112 CDA component (DYNAMIC)
hl7:component
1 … 1RCDAcdotsnent
@typeCode
cs0 … 1FCOMP
@contextConductionInd
bl0 … 1Ftrue
Choice1 … 1Elements to choose from:
Included from 2.16.840.1.113883.10.12.203 CDA NonXMLBody (DYNAMIC)
hl7:nonXMLBody
CDANdotsBody
@classCode
cs0 … 1FDOCBODY
@moodCode
cs0 … 1FEVN
hl7:text
ED1 … 1CDANdotsBody
hl7:confidentialityCode
CE0 … 1CDANdotsBody
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)
hl7:languageCode
CS0 … 1CDANdotsBody
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
Included from 2.16.840.1.113883.10.12.202 CDA StructuredBody (DYNAMIC)
hl7:structuredBody
CDASdotsBody
@classCode
cs0 … 1FDOCBODY
@moodCode
cs0 … 1FEVN
hl7:confidentialityCode
CE0 … 1CDASdotsBody
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC)
hl7:languageCode
CS0 … 1CDASdotsBody
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:component
1 … *Contains 2.16.840.1.113883.10.12.201 CDA Section (DYNAMIC)CDASdotsBody
@typeCode
cs0 … 1FCOMP
@contextConductionInd
bl0 … 1Ftrue
Included0 … 1 from 2.16.840.1.113883.10.12.113 CDA componentOf (DYNAMIC)
hl7:componentOf
0 … 1CDAcdotsntOf
@typeCode
cs0 … 1FCOMP
hl7:encompassingEncounter
1 … 1CDAcdotsntOf
@classCode
cs0 … 1FENC
@moodCode
cs0 … 1FEVN
hl7:id
II0 … *CDAcdotsntOf
hl7:code
CE0 … 1CDAcdotsntOf
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC)
hl7:effectiveTime
IVL_TS1 … 1RCDAcdotsntOf
hl7:dischargeDispositionCode
CE0 … 1CDAcdotsntOf
 CONF
shall be drawn from concept domain "EncounterDischargeDisposition"
hl7:responsibleParty
0 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAcdotsntOf
@typeCode
cs0 … 1FRESP
hl7:encounterParticipant
0 … *CDAcdotsntOf
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC)
hl7:time
IVL_TS0 … 1CDAcdotsntOf
hl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAcdotsntOf
hl7:location
0 … 1CDAcdotsntOf
@typeCode
cs0 … 1FLOC
hl7:healthCareFacility
1 … 1CDAcdotsntOf
@classCode
cs0 … 1FSDLOC
hl7:id
II0 … *CDAcdotsntOf
hl7:code
CE0 … 1CDAcdotsntOf
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC)
hl7:location
0 … 1Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC)CDAcdotsntOf
hl7:serviceProviderOrganization
0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)CDAcdotsntOf
Included0 … 1R from 2.16.840.1.113883.3.1937.99.61.5.10.900277 APSR2 Intraoperative Observation Section (2014‑05‑13 19:29:16)
hl7:section
0 … 1RAPSRdotstion
@classCode
cs0 … 1FDOCSECT
@moodCode
cs0 … 1FEVN
hl7:templateId
II1 … 1RAPSRdotstion
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.5.10.900277
hl7:id
II0 … 1APSRdotstion
hl7:code
CE0 … 1APSRdotstion
 Constraintde-DE Only LOINC code allowed, for that special section not yet defined
@code
CONF0 … 1F57027-5
@codeSystem
0 … 1F2.16.840.1.113883.6.1
@displayName
0 … 1FMeasurement and observation
@codeSystemName
0 … 1FLOINC
hl7:title
ST0 … 1APSRdotstion
 CONF
element content shall be "Intraoperative observation"
hl7:text
SD.TEXT0 … 1RAPSRdotstion
hl7:languageCode
CS0 … 1APSRdotstion
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:author
0 … *Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)APSRdotstion
hl7:entry
0 … *Contains 2.16.840.1.113883.3.1937.99.61.5.10.900280 APSR2 AP Observation Entry (DYNAMIC)APSRdotstion
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
@contextConductionInd
bl0 … 1 
Included1 … 1R from 2.16.840.1.113883.3.1937.99.61.5.10.900279 APSR2 Procedure Steps Section (2014‑05‑13 19:33:12)
hl7:section
1 … 1RAPSRdotstion
@classCode
cs0 … 1FDOCSECT
@moodCode
cs0 … 1FEVN
hl7:templateId
II1 … 1RAPSRdotstion
@root
uid1 … 1F2.16.840.1.113883.10.12.201
hl7:templateId
II1 … 1MAPSRdotstion
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.5.10.900279
hl7:id
II0 … 1APSRdotstion
hl7:code
CE0 … 1RAPSRdotstion
 Constraintde-DE Only LOINC code allowed
@code
CONF0 … 1F46059-2
@codeSystem
0 … 1F2.16.840.1.113883.6.1
@displayName
0 … 1FSpecial treatments and procedures section
@codeSystemName
0 … 1FLOINC
hl7:title
ST1 … 1MAPSRdotstion
 CONF
element content shall be "PROCEDURE STEPS"
hl7:text
SD.TEXT1 … 1MAPSRdotstion
 Example<text>Part #1 is labeled “left breast biopsy” and has been sampled for frozen section
preparation. Numerous sections are submitted for permanent processing. Part #2
received in two pieces is labeled "apical left axillary tissue". Both pieces are
rendered into numerous sections and submitted in their entirety for history.
</text>
hl7:entry
1 … 1RContains 2.16.840.1.113883.3.1937.99.61.5.10.900283 APSR2 Specimen procedure step Entry (DYNAMIC)APSRdotstion
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
@contextConductionInd
bl0 … 1 
Included1 … 1M from 2.16.840.1.113883.3.1937.99.61.5.10.900278 APSR2 Diagnostic Conclusion Section (2014‑05‑13 19:31:26)
hl7:section
1 … 1MAPSRdotstion
@classCode
cs0 … 1FDOCSECT
@moodCode
cs0 … 1FEVN
hl7:templateId
II1 … 1RAPSRdotstion
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.5.10.900278
hl7:id
II0 … 1APSRdotstion
hl7:code
CE0 … 1APSRdotstion
 Constraintde-DE Only LOINC code allowed
@code
CONF0 … 1F22637-3
@codeSystem
0 … 1F2.16.840.1.113883.6.1
@displayName
0 … 1F'Pathology report diagnosis
@codeSystemName
0 … 1FLOINC
hl7:title
ST1 … 1MAPSRdotstion
 CONF
element content shall be "Diagnostic conclusion"
hl7:text
SD.TEXT1 … 1MAPSRdotstion
 Example
Diagnosis
<text>
Invasive breast cancer, no special type

TNM: pT1c pN0(0/3sn) L0 V0 R0 G2
ICD-O-3: 8500/3
</text>
hl7:author
0 … *Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)APSRdotstion
hl7:entry
1 … *MContains 2.16.840.1.113883.3.1937.99.61.5.10.900280 APSR2 AP Observation Entry (DYNAMIC)APSRdotstion
Included0 … 1R from 2.16.840.1.113883.3.1937.99.61.5.10.900275 APSR2 Clinical Information Section (2014‑05‑13 14:38:08)
hl7:section
0 … 1RAPSRdotstion
hl7:templateId
II1 … 1RAPSRdotstion
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.5.10.900275
hl7:code
CE0 … 1APSRdotstion
@code
CONF0 … 1F22636-5
@codeSystem
0 … 1F2.16.840.1.113883.6.1
@displayName
0 … 1FPathology report relevant history
@codeSystemName
0 … 1FLOINC
hl7:title
ST0 … 1APSRdotstion
 Example<title>CLINICAL INFORMATION</title>
hl7:text
SD.TEXT0 … 1RAPSRdotstion
 Example<text> Tissue submitted: left breast biopsy and apical axillary tissue </text>
hl7:languageCode
CS0 … 1APSRdotstion
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:author
0 … *Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)APSRdotstion
hl7:component
0 … *APSRdotstion
Included0 … * from 2.16.840.1.113883.3.1937.99.61.5.10.900281 Reason for Referral Section (DYNAMIC)
hl7:section
0 … *Reasdotstion
@classCode
cs0 … 1FDOCSECT
@moodCode
cs0 … 1FEVN
hl7:templateId
II1 … 1RReasdotstion
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.3.1
hl7:templateId
II1 … 1MReasdotstion
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.5.10.900281
hl7:code
CD1 … 1MReasdotstion
@code
CONF1 … 1F42349-1
@codeSystem
1 … 1F2.16.840.1.113883.6.1
hl7:title
ST1 … 1MReasdotstion
 Example<title>Reason for anatomic pathology procedure</title>
hl7:text
SD.TEXT1 … 1MReasdotstion
 Example<text>Breast mass - left breast</text>
hl7:component
0 … *APSRdotstion
Included0 … * from 2.16.840.1.113883.3.1937.99.61.5.10.900282 History of Present Illness Section (DYNAMIC)
hl7:section
0 … *Histdotsness
@classCode
cs0 … 1FDOCSECT
@moodCode
cs0 … 1FEVN
hl7:templateId
II1 … 1RHistdotsness
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.3.4
hl7:templateId
II1 … 1MHistdotsness
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.5.10.900282
hl7:code
CD1 … 1MHistdotsness
@code
CONF1 … 1F10164-2
@codeSystem
1 … 1F2.16.840.1.113883.6.1
hl7:title
ST1 … 1MHistdotsness
 Example<title> History of present illness </title>
hl7:text
SD.TEXT1 … 1MHistdotsness
 Example<text>Carcinoma of breast. Post operative diagnosis: same. Left UOQ breast mass. </text>
Included1 … 1R from 2.16.840.1.113883.3.1937.99.61.5.10.900274 APSR2 Microscopic Observation Section (2014‑05‑13 14:25:17)
hl7:section
1 … 1RAPSRdotstion
hl7:templateId
II1 … 1RAPSRdotstion
@root
uid1 … 1F2.16.840.1.113883.10.12.201
hl7:templateId
II1 … 1MAPSRdotstion
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.5.10.900274
hl7:code
CE1 … 1RAPSRdotstion
 Constraintde-DE Only LOINC code allowed
@code
CONF0 … 1F22635-7
@codeSystem
0 … 1F2.16.840.1.113883.6.1
@displayName
0 … 1FPathology report microscopic observation
@codeSystemName
0 … 1FLOINC
hl7:title
ST0 … 1RAPSRdotstion
 CONF
element content shall be "Microscopic observation"
 Example<title>MICROSCOPIC OBSERVATION SECTION</title>
hl7:text
SD.TEXT0 … 1RAPSRdotstion
 Example<text>
Sections of part #1 confirm frozen section diagnosis of infiltrating duct
carcinoma. It is to be noted that the tumor cells show considerable pleomorphism,
and mitotic figures are frequent (as many as 4 per high power field). Total size of
primary tumor is estimated to be 3cm in greatest dimension. Many foci of
calcification are present within the tumor. Part #2 consists of fibrofatty tissue
and includes 18 lymph nodes. All lymph nodes are free of disease with the exception
of one lymph node, which contains several micrometastases.
</text>
hl7:entry
0 … *Contains 2.16.840.1.113883.3.1937.99.61.5.10.900280 APSR2 AP Observation Entry (DYNAMIC)APSRdotstion
Included1 … 1R from 2.16.840.1.113883.3.1937.99.61.5.10.900272 APSR2 Macroscopic Observation Section (DYNAMIC)
hl7:section
1 … 1RAPSRdotstion
hl7:templateId
II1 … 1RAPSRdotstion
@root
uid1 … 1F2.16.840.1.113883.10.12.201
hl7:templateId
II1 … 1MAPSRdotstion
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.5.10.900272
hl7:id
II0 … 1APSRdotstion
hl7:code
CE1 … 1RAPSRdotstion
 Constraintde-DE Only LOINC code allowed
@code
CONF0 … 1F22634-0
@codeSystem
0 … 1F2.16.840.1.113883.6.1
@displayName
0 … 1FPathology report gross observation
@codeSystemName
0 … 1FLOINC
hl7:title
ST0 … 1RAPSRdotstion
 CONF
element content shall be "Macroscopic observation"
 Example<title>Macroscopic Observation</title>
hl7:text
SD.TEXT0 … 1RAPSRdotstion
 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)APSRdotstion
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Included0 … 1R from 2.16.840.1.113883.3.1937.99.61.5.10.900303 APSR2 Specimen Section (DYNAMIC)
hl7:section
0 … 1RAPSRdotstion
@classCode
cs0 … 1FDOCSECT
@moodCode
cs0 … 1FEVN
hl7:templateId
II1 … 1MAPSRdotstion
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.5.10.900303
hl7:templateId
II1 … 1RAPSRdotstion
@root
uid1 … 1F2.16.840.1.113883.10.12.201
hl7:id
II0 … 1APSRdotstion
hl7:title
ST0 … 1APSRdotstion
 CONF
element content shall be "Specimen"
hl7:text
SD.TEXT0 … 1Rde-DE The text in the section may contain additional describing information about the specimen and their preparation. It may comprise of a tabular list of all details (container, containment, Identifier, etc.).APSRdotstion
hl7:entry
1 … 1Rde-DE The entry relationship is used to insert an organizer with all the specimen details in structured form.
Contains 2.16.840.1.113883.3.1937.99.61.5.10.900304 APSR2 Specimen Organizer (DYNAMIC)		APSRdotstion