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Template APSR2 Specimen procedure step Entry 2014‑07‑29 16:02:02

Id2.16.840.1.113883.3.1937.99.61.5.10.900283Effective Date2014‑07‑29 16:02:02
Statusdraft DraftVersion Label
NameCDAProcedureDisplay NameAPSR2 Specimen procedure step Entry
Description
Template CDA Procedure (prototype, directly derived from POCD_RM000040 MIF)
ContextParent nodes of template element with id 2.16.840.1.113883.3.1937.99.61.5.10.900283
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 3 templates, Uses 4 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
2.16.840.1.113883.3.1937.99.61.5.10.900222Containmentretired eLab_Spezimen-Act2013‑12‑05 11:40:39
2.16.840.1.113883.3.1937.99.61.5.10.900273linkdraft Anatomic Pathology Structured Report2014‑05‑13 11:57:57
2.16.840.1.113883.3.1937.99.61.5.10.900279Containmentdraft APSR2 Procedure Steps Section2014‑05‑13 19:33:12
Uses as NameVersion
2.16.840.1.113883.3.1937.99.61.5.10.900224Containmentdraft eLab_CDA Performer (Body)DYNAMIC
2.16.840.1.113883.3.1937.99.61.5.10.900284Includedraft CDA Participant (Body) APSRDYNAMIC
2.16.840.1.113883.10.12.318Containmentactive CDA Author (Body)DYNAMIC
2.16.840.1.113883.10.12.322Containmentactive CDA SpecimenDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.306 CDA Procedure (2005‑09‑07)
ref
ad1bbr-
Example
Specimen procedure step entry
<procedure negationInd="false" classCode="PROC" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.12.306"/>  <templateId root="2.16.840.1.113883.3.1937.99.61.5.10.900283"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="17636008" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen collection (procedure)"/>  <text/>  <statusCode code="normal"/>  <effectiveTime>
    <low value="20141226122646"/>  </effectiveTime>  <methodCode/>  <targetSiteCode/>  <specimen>
    <!-- template 2.16.840.1.113883.10.12.322 (dynamic) -->
  </specimen>  <performer>
    <!-- template CDAPerformerBody (dynamic) -->
  </performer>  <author>
    <!-- template CDAAuthorBody (dynamic) -->
  </author>  <participant>
    <!-- include template 2.16.840.1.113883.3.1937.99.61.5.10.900284 (dynamic) 1..1 M-->
  </participant></procedure>
ItemDTCardConfDescriptionLabel
hl7:procedure
1 … *RCDAPdotsdure
@classCode
cs1 … 1FPROC
@moodCode
cs1 … 1FEVN
@negationInd
bl0 … 1 
hl7:templateId
II1 … 1RCDAPdotsdure
@root
uid1 … 1F2.16.840.1.113883.10.12.306
hl7:templateId
II1 … 1MCDAPdotsdure
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.5.10.900283
hl7:id
II0 … *CDAPdotsdure
hl7:code
CD1 … 1RCDAPdotsdure
 Constraintde-DE for specimen collection procedure codes for targetSite or PathLex or SNOMED CT have to be used, for specimen processing (down step the procedures) SNOMED CT is preferred, DICOM could be used if available
 CONF
@code shall be "17636008"
@codeSystem shall be "2.16.840.1.113883.6.96"
@displayName shall be "Specimen collection (procedure)"
@codeSystemName shall be "SNOMED CT"
or
@code shall be "40923002"
@codeSystem shall be "2.16.840.1.113883.6.96"
@displayName shall be "Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)"
@codeSystemName shall be "SNOMED CT"
hl7:text
ED0 … 1CDAPdotsdure
 Example
specimen (collection/processing) procedure
<text>ULTRASOUND GUIDED NEEDLE CORE BIOPSY</text>
hl7:statusCode
CS0 … 1CDAPdotsdure
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
hl7:effectiveTime
IVL_TS0 … 1CDAPdotsdure
hl7:methodCode
CE0 … *CDAPdotsdure
@codeSystem
CONF0 … 1F2.16.840.1.113883.5.1065
hl7:targetSiteCode
CD0 … *CDAPdotsdure
@codeSystem
CONF0 … 1F2.16.840.1.113883.5.1052
hl7:specimen
0 … *Contains 2.16.840.1.113883.10.12.322 CDA Specimen (DYNAMIC)CDAPdotsdure
hl7:performer
0 … *Contains 2.16.840.1.113883.3.1937.99.61.5.10.900224 eLab_CDA Performer (Body) (DYNAMIC)CDAPdotsdure
hl7:author
0 … *Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)CDAPdotsdure
hl7:participant
0 … 1CDAPdotsdure
Included1 … 1M from 2.16.840.1.113883.3.1937.99.61.5.10.900284 CDA Participant (Body) APSR (DYNAMIC)
 Example
Specimen collected or processed
<participant typeCode="PRD">
  <participantRole classCode="SPEC">
    <!-- specimen ids -->
    <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="A7102400008"/>    <playingEntity>
      <!-- need a code in PATHLEX for "part obtained from a biopsy -->
      <code code="theCode" codeSystem="1.3.6.1.4.1.19376.1.8.2.1" displayName="part collected by biopsy" codeSystemName="PATHLEX"/>    </playingEntity>  </participantRole></participant>
@typeCode
cs1 … 1FPRD
@contextControlCode
cs1 … 1FOP
hl7:time
IVL_TS1 … 1MCDAPdotsPSR2
hl7:participantRole
1 … 1MCDAPdotsPSR2
@classCode
cs0 … 1FSPEC
hl7:id
II1 … 1MCDAPdotsPSR2
hl7:id
II1 … 1MCDAPdotsPSR2
 Constraintde-DE This Id is the paraentId, i.e. the id of the parent of this specimen
hl7:code
CE0 … 1CDAPdotsPSR2
@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111
Included from 2.16.840.1.113883.3.1937.99.61.5.10.900285 CDA PlayingEntity APSR2 (DYNAMIC)
@classCode
cs0 … 1FENT
@determinerCode
cs0 … 1FINSTANCE
hl7:code
CE0 … 1de-DE Codes for
- classCode
- typeCode
- subTypeCode
- isDerived
- specimenRole
- specimenChildRole
- specimenGroupCount		CDAPdotsPSR2
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16040 EntityCode (DYNAMIC)
or
@code shall be "see example "
or
@code shall be "119376003"
@codeSystem shall be "2.16.840.1.113883.6.96"
@displayName shall be "Tissue, unspecified"
@codeSystemName shall be "SNOMED-CT"
or
@code shall be "TISS"
@codeSystem shall be "2.16.840.1.113883.5.129"
@codeSystemName shall be "HL7"
 Example
example for PathLex
<playingEntity>
  <!-- Need codes in PathLex for "part obtained by e.g.biopsy" -->
  <code code="theCode" codeSystem="1.3.6.1.4.1.19376.1.8.2.1" displayName="part collected by e.g.biopsy" codeSystemName="PathLex"/></playingEntity>
hl7:quantity
PQ0 … *CDAPdotsPSR2
hl7:name
PN0 … *CDAPdotsPSR2
hl7:desc
ED0 … 1CDAPdotsPSR2