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Template APSR2 Clinical Information Section 2014‑05‑13 14:38:08

Id2.16.840.1.113883.3.1937.99.61.5.10.900275Effective Date2014‑05‑13 14:38:08
Statusdraft DraftVersion Label
NameAPSR2ClinicalInformationSectionDisplay NameAPSR2 Clinical Information Section
Description
The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, reason for anatomic pathology procedure, clinical laboratory data, information about specimens collected in this case (including target site, performer, specimen type, specimen(s) clinical description, and tumor site in case of a cancer).
ContextParent nodes of template element with id 2.16.840.1.113883.3.1937.99.61.5.10.900275
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 1 template, Uses 3 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
2.16.840.1.113883.3.1937.99.61.5.10.900273Includedraft Anatomic Pathology Structured Report2014‑05‑13 11:57:57
Uses as NameVersion
2.16.840.1.113883.3.1937.99.61.5.10.900281Includedraft Reason for Referral SectionDYNAMIC
2.16.840.1.113883.3.1937.99.61.5.10.900282Includedraft History of Present Illness SectionDYNAMIC
2.16.840.1.113883.10.12.318Containmentactive CDA Author (Body)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
Example
Example
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    <!-- template CDAAuthorBody (dynamic) -->
  </author>  <component>
    <!-- include template 2.16.840.1.113883.3.1937.99.61.5.10.900281 (dynamic) 0..* O-->
  </component>  <component>
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  </component></section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … *APSRdotstion
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>