Template

Show index

Template APSR2 Diagnostic Conclusion Section 2014‑05‑13 19:31:26

Id2.16.840.1.113883.3.1937.99.61.5.10.900278Effective Date2014‑05‑13 19:31:26
Statusdraft DraftVersion Label
NameAPSR2DiagnosticConclusionSectionDisplay NameAPSR2 Diagnostic Conclusion Section
Description
The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.
ContextParent nodes of template element with id 2.16.840.1.113883.3.1937.99.61.5.10.900278
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 1 template, Uses 2 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
2.16.840.1.113883.3.1937.99.61.5.10.900280Containmentdraft APSR2 AP Observation EntryDYNAMIC
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
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="2.16.840.1.113883.3.1937.99.61.5.10.900278"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="22637-3" codeSystem="2.16.840.1.113883.6.1" displayName="'Pathology report diagnosis"/>  <title>Diagnostic conclusion</title>  <text/>  <author>
    <!-- template CDAAuthorBody (dynamic) -->
  </author>  <entry>
    <!-- template 2.16.840.1.113883.3.1937.99.61.5.10.900280 (dynamic) -->
  </entry></section>
ItemDTCardConfDescriptionLabel
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