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Template APSR2 Microscopic Observation Section 2014‑05‑13 14:25:17

Id2.16.840.1.113883.3.1937.99.61.5.10.900274Effective Date2014‑05‑13 14:25:17
Statusdraft DraftVersion Label
NameAPSR2MicroscopySectionDisplay NameAPSR2 Microscopic Observation Section
Description
The Microscopic Observation section contains optionally the histopathologic findings of the case and of all of the derived specimens. This section should be used to record the results of histochemical and immunohistochemical stains and of image-based molecular methods.
ContextParent nodes of template element with id 2.16.840.1.113883.3.1937.99.61.5.10.900274
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 1 template, Uses 1 template
Used by as NameVersion
2.16.840.1.113883.3.1937.99.61.5.4.22Transactiondraft CDA Document APSR22014‑11‑16 11:45:10
2.16.840.1.113883.3.1937.99.61.5.10.900273Includedraft Anatomic Pathology Structured Report2014‑05‑13 11:57:57
Uses as NameVersion
2.16.840.1.113883.3.1937.99.61.5.10.900280Containmentdraft APSR2 AP Observation EntryDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
Example
Example
<section>
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.4"/>  <code code="22635-7" displayName="Pathology report microscopic observation" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <title>MICROSCOPIC OBSERVATION SECTION</title>  <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>  <entry>
    <!--Content not shown -->
  </entry></section>
ItemDTCardConfDescriptionLabel
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hl7:templateId
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@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