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Template Specimen Procedure Step 2016‑07‑08 13:20:59

Id1.3.6.1.4.1.19376.1.3.10.4.1Effective Date2016‑07‑08 13:20:59
Statusdraft DraftVersion Label2.0
NameSpecimenProcedureStepDisplay NameSpecimen Procedure Step
Description
Template CDA Procedure (prototype, directly derived from POCD_RM000040 MIF)
for Specimen procedure step in APSR 2.

This entry collects all the information of source, method and outcome of a specimen procedure from the collection out of the patient through the final product of a stained histologic section or cytologic smear on a glass slide, or a WSI of such a slide. It reflects the workflow and the probe tracking of a pathology laboratory.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.1
LabelPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 13 concepts
IdNameData Set
psr-dataelement-95draft Parent ID draft APSR 2.0
psr-dataelement-17draft Specimen identification draft APSR 2.0
psr-dataelement-67draft Block ID draft APSR 2.0
psr-dataelement-68draft Tissue section ID draft APSR 2.0
psr-dataelement-98draft Specimen ID draft APSR 2.0
psr-dataelement-66draft Part ID draft APSR 2.0
psr-dataelement-24draft Specimen collection draft APSR 2.0
psr-dataelement-25draft Specimen processing draft APSR 2.0
psr-dataelement-89draft Procedure Step draft APSR 2.0
psr-dataelement-90draft Requested Procedure draft APSR 2.0
psr-dataelement-94draft Target Site draft APSR 2.0
psr-dataelement-101draft Work order step draft APSR 2.0
psr-dataelement-87draft Procedure ID draft APSR 2.0
Used by / Uses
Used by 1 transaction and 3 templates, Uses 7 templates
Used by as NameVersion
2.16.840.1.113883.2.6.60.6.4.2Transactiondraft CDA Document Anatomic Pathology Structured Report 2015 (2.0)2015‑10‑23 10:32:36
1.3.6.1.4.1.19376.1.3.10.4.1Containmentcancelled Specimen Procedure Step (1.0)2014‑07‑29 16:02:02
1.3.6.1.4.1.19376.1.8.1.1.1linkdraft Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.6Containmentdraft Procedure Steps Section (2.0)2014‑05‑13 19:33:12
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.1.3Containmentactive Specimen Received (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.3.1.7Containmentactive Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.10.9.1Includedraft X Specimen Identified (2.0)2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.3.10.9.22Containmentdraft Specimen Container in Procedure Step (2.0)2016‑07‑29 12:09:33
1.3.6.1.4.1.19376.1.3.10.9.44Containmentdraft CDA Participant (Body) Procedure Steps APSR2 (2.0)2014‑10‑26 17:06:28
1.3.6.1.4.1.19376.1.8.1.4.2Containmentdraft Author (2.0)2016‑06‑21 14:02:11
2.16.840.1.113883.10.12.324Containmentactive CDA Reference2005‑09‑07
RelationshipAdaptation: template 2.16.840.1.113883.10.12.306 CDA Procedure (2005‑09‑07)
ref
ad1bbr-
Example
example for use case #1, Sectioning and ER-Immuno-Staining
<procedure negationInd="false" classCode="PROC" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.4.1"/>  <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008-P4"/>  <code code="117617002" codeSystem="2.16.840.1.113883.6.96" displayName="Immunohistochemistry procedure (procedure)">
    <qualifier>
      <name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/>      <value code="23307004" displayName="Estrogen receptor (substance)" codeSystem="2.16.840.1.113883.6.96"/>    </qualifier>  </code>  <statusCode code="completed"/>  <effectiveTime>
    <low value="201001030925-0500"/>  </effectiveTime>  <targetSiteCode code="441652008" codeSystem="2.16.840.1.113883.6.96" displayName="Formalin-fixed paraffin-embedded tissue specimen (specimen)"/>  <!-- PARENT SPECIMEN on which the procedure step is performed -->
  <specimen typeCode="SPC">
    <specimenRole classCode="SPEC">
      <!-- Parent specimen ID -->
      <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_block_A_1"/>    </specimenRole>  </specimen>  <!-- Specimen processor: the lab technician in this case -->
  <performer typeCode="PRF">
    <time>
      <low value="201001030925-0500"/>    </time>    <modeCode code="PHYSICAL" displayName="physical presence" codeSystem="2.16.840.1.113883.5.1064"/>    <assignedEntity>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="member#32"/>      <assignedPerson>
        <name>
          <given>John</given>          <family>Labtech</family>        </name>      </assignedPerson>    </assignedEntity>  </performer>  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->
  </author>  <!--Product of the procedure, i.e. specimen -->
  <participant typeCode="PRD" contextControlCode="OP">
    <time>
      <low value="201001030925-0500"/>    </time>    <!-- ID of the specimen produced, coming from the LIS -->
    <participantRole classCode="SPEC">
      <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_slide_A_1_ER"/>      <code code="P" codeSystem="2.16.840.1.113883.5.111"/>      <playingEntity classCode="ENT" determinerCode="INSTANCE">
        <code code="TISS" displayName="Tissue, unspecified" codeSystem="2.16.840.1.113883.5.1060"/>        <quantity value="1"/>        <desc/>      </playingEntity>    </participantRole>  </participant>  <entryRelationship negationInd="false" typeCode="COMP" inversionInd="false" contextConductionInd="true">
    <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.22 'CDA Supply Container APSR2' (2016-07-29T12:09:33) -->
  </entryRelationship>  <entryRelationship typeCode="COMP" inversionInd="false" contextConductionInd="true" negationInd="false">
    <act classCode="ACT" moodCode="EVN" negationInd="false">
      <templateId root="1.3.6.1.4.1.19376.1.3.1.3"/>      <code code="SPRECEIVE" codeSystem="1.3.5.1.4.1.19376.1.5.3.2" displayName="Specimen received" codeSystemName="IHEActCode"/>      <effectiveTime>
        <low value="201001030925-0500"/>      </effectiveTime>    </act>  </entryRelationship>  <entryRelationship typeCode="REFR" inversionInd="false" contextConductionInd="true" negationInd="false">
    <seperatableInd value="false"/>    <procedure classCode="PROC" moodCode="EVN" negationInd="false">
      <!-- ID of the child procedure, coming from LIS -->
      <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008-P5"/>    </procedure>  </entryRelationship></procedure>
ItemDTCardConfDescriptionLabel
hl7:procedure
0 … *RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
 
target
psr-dataelement-24draft Specimen collection draft APSR 2.0
psr-dataelement-25draft Specimen processing draft APSR 2.0
psr-dataelement-90draft Requested Procedure draft APSR 2.0
psr-dataelement-101draft Work order step draft APSR 2.0
@classCode
cs1 … 1FPROC
@moodCode
cs1 … 1FEVN
hl7:templateId
II1 … 1RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.4.1
hl7:id
II0 … *RProcedure ID, coming from the LIS.
May be the target (referenced) ID for the child procedure.		PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
 
target
psr-dataelement-89draft Procedure Step draft APSR 2.0
psr-dataelement-87draft Procedure ID draft APSR 2.0
hl7:code
CD (extensible)1 … 1MCoded procedurePaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
 Constraintfor specimen collection procedure codes for targetSite 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
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.10 Specimen Collection and Processing (2016‑05‑31 15:09:59)
 Example
for use case #1, specimen collection
<code code="122548005" codeSystem="2.16.840.1.113883.6.96" displayName="Biopsy of breast (procedure)" codeSystemName="SNOMED-CT"/>
 Example
for use case #1, grossing & embedding
<code code="40923002" codeSystem="2.16.840.1.113883.6.96" displayName="Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)"/>
 Example
for use case #1, sectioning & immunostaining
<code code="117617002" codeSystem="2.16.840.1.113883.6.96" displayName="Immunohistochemistry procedure (procedure)"/>
hl7:qualifier
CR (extensible)0 … *CQualifier for staining or other procedures which don´t have values in the vocabulary used.PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
 ConstraintUsed only in staining and other procedures without values in SCT or LOINC or DICOM vocabulary, e.g. immune stains
 Example
for use case #1, grossing & embedding
<qualifier>
  <name code="246355002" displayName="Supporting structure (attribute)" codeSystem="2.16.840.1.113883.6.96"/>  <value code="702941008" displayName="Paraffin embedding (qualifier value)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT"/></qualifier>
 Example
for use case #1, Estrogen receptor staining
<qualifier>
  <name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/>  <value code="23307004" displayName="Estrogen receptor (substance)" codeSystem="2.16.840.1.113883.6.96"/></qualifier>
 Example
for use case #1, ISH Her-2-neu staining
<qualifier>
  <name code="246094008" displayName="Component investigated (attribute)" codeSystem="2.16.840.1.113883.6.96"/>  <value code="164870" displayName="ONCOGENE ERBB2" codeSystem="2.16.840.1.113883.6.174" codeSystemName="OMIM"/></qualifier>
hl7:name
CV (extensible)1 … 1RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
@code
cs0 … 1F246094008_or_246355002
@codeSystem
oid0 … 1F2.16.840.1.113883.6.96
@displayName
st0 … 1FComponent investigated (attribute) or Supporting structure (attribute)
hl7:value
CD (extensible)1 … 1RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
@nullFlavor
cs1 … 1R
 CONF
@code shall be "<<105590001 | Substance (substance) |"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SNOMED-CT"
@displayName shall be "values from substance axis, e.g. Estrogen receptor"
or
@code shall be "values from G axis"
@codeSystem shall be "2.16.840.1.113883.6.174"
@codeSystemName shall be "OMIM"
@displayName shall be "values from G axis, e.g. erb-b2"
or
@code shall be "<<272394005 | Technique (qualifier value) |"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SNOMED-CT"
@displayName shall be "values from technique axis, e.g. Paraffin embedded (qualifier)"
hl7:text
ED0 … 1RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
 Example
specimen collection procedure
<text>ULTRASOUND GUIDED NEEDLE CORE BIOPSY</text>
 Example
specimen processing procedure
<text>CUTTING A SLIDE FROM A PARAFFIN BLOCK</text>
hl7:statusCode
CS (required)0 … 1RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
 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 … 1RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
hl7:approachSiteCode
CD (extensible)0 … 1RApproach site in specimen collectionPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
@code
CONF0 … 1Fany_code
@codeSystem
0 … 1F2.16.840.1.113883.5.1052
@codeSystemName
0 … 1Fany_code
@displayName
0 … 1FActSite
hl7:targetSiteCode
CD (extensible)0 … 1RTarget site in body or relative parent relationship in case of specimen processingPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
 
target
psr-dataelement-94draft Target Site draft APSR 2.0
 CONF
@code shall be "<<123037004 | Body structure (body structure) |"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SCT"
@displayName shall be "all children of Body structure (body structure)"
or
@code shall be "any_code"
@codeSystem shall be "2.16.840.1.113883.5.1052"
@codeSystemName shall be "ActSite"
@displayName shall be "any_code"
or
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.9 Procedure Site (2016‑06‑01 18:46:15)
 Example
for use case #1, specimen collection
<targetSiteCode code="110497008" displayName="Lower outer quadrant of right breast (body structure)" codeSystem="2.16.840.1.113883.6.96"/>
 Example
for use case #1, grossing & embedding
<targetSiteCode code="309050000" displayName="Body substance sample" codeSystem="2.16.840.1.113883.6.96"/>
hl7:qualifier
CR (extensible)0 … *Coptional qualifiers for specifying body structures or / and lateralityPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
 Example
for use case #1, (optional) specification of body structure for specimen collection
<qualifier>
  <name code="118169006" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen source topography (attribute)" codeSystemName="SNOMED-CT"/>  <value code="255495000" codeSystem="2.16.840.1.113883.6.96" displayName="Right lower quadrant (qualifier value)" codeSystemName="SNOMED-CT"/></qualifier>
hl7:name
CV (extensible)1 … 1RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
@displayName
st0 … 1FSpecimen source topography
@codeSystem
oid1 … 1F2.16.840.1.113883.6.96
@code
cs1 … 1F118169006
hl7:value
CD (extensible)0 … *RPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
@code
CONF0 … 1F<<272099008
@codeSystem
0 … 1F2.16.840.1.113883.6.96
@codeSystemName
0 … 1FSCT
@displayName
0 … 1Fall children of Descriptor (qualifier values) e.g. right lower quadrant
hl7:methodCode
CD (extensible)0 … *RIdentifies the technique used to perform a procedurePaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
@codeSystem
cs1 … 1F2.16.840.1.113883.5.1065
Included0 … 1R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Parent specimen with parent ID
 Example
for use case #1, parent specimen ID in grossing & embedding
<specimen typeCode="SPC">
  <specimenRole classCode="SPEC">
    <!-- Parent specimen ID -->
    <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008"/>  </specimenRole></specimen>
 ConstraintID element of the parent specimen SHOULD be used only
hl7:specimen
0 … 1RRequired in XD-LAB when more than one specimen is documented at this level. Always required in APSR.PaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified
 
target
psr-dataelement-17draft Specimen identification draft APSR 2.0
@typeCode
cs0 … 1FSPC
hl7:specimenRole
1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified
@classCode
cs0 … 1FSPEC
hl7:id
II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified
 
target
psr-dataelement-95draft Parent ID draft APSR 2.0
psr-dataelement-67draft Block ID draft APSR 2.0
psr-dataelement-68draft Tissue section ID draft APSR 2.0
psr-dataelement-98draft Specimen ID draft APSR 2.0
psr-dataelement-66draft Part ID draft APSR 2.0
hl7:performer
0 … 1RContains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
hl7:author
0 … *CContains 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11)PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
hl7:participant
1 … *MOne or more specimen (with additives), which participates as product of the procedure
Contains 1.3.6.1.4.1.19376.1.3.10.9.44 CDA Participant (Body) Procedure Steps APSR2 (2014‑10‑26 17:06:28)		PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
hl7:entryRelationship
0 … *RSpecimen container (manufactured product)
Contains 1.3.6.1.4.1.19376.1.3.10.9.22 Specimen Container in Procedure Step (2016‑07‑29 12:09:33)		PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl0 … 1Ftrue
 Constraintfor manufactured product
classCode = MANU

for DrugOrOtherMaterial
classCode = MMAT
code from MaterialEntityClassType
hl7:entryRelationship
0 … 1RSpecimen arrival in Lab
Contains 1.3.6.1.4.1.19376.1.3.1.3 Specimen Received (2008‑08‑08)		PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl0 … 1Ftrue
hl7:entryRelationship
0 … *RReferencing mechanism to the ID of the child procedures, giving a lis of child procedure IDsPaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
@typeCode
cs1 … 1FREFR
@contextConductionInd
bl0 … 1Ftrue
 Constraintcontains only ID(s) of the child procedure(s), which is(are) fully described in dedicated entry(s) further down in the Procedure step section.
hl7:procedure
1 … 1RChild procedurePaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
@classCode
cs1 … 1FPROC
@moodCode
cs1 … 1FEVN
hl7:id
II1 … *RID of the child procedure, coming from the LIS.PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps
hl7:reference
0 … *RReference to an external document, or to external procedures, e.g. concerning molecular pathology or  genetic testing report
Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)		PaLM Suppl. 2.1‑3: 6.3.2.3 Specimen procedure steps