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Template Assessment Scales Observation for Scoring Systems 2016‑10‑06 13:12:00

Id1.3.6.1.4.1.19376.1.3.10.4.4Effective Date2016‑10‑06 13:12:00
Statusdraft DraftVersion Label2.0
NameAssessmentScalesObservationScoringSystemsAPSRDisplay NameAssessment Scales Observation for Scoring Systems
Description
Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF)

Assessment scale observation for Scoring Systems, e.g. Nottingham- (Elston-Ellis-) Grading for invasive breast cancers, describing the summarized scale value
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.4.4
LabelPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
ClassificationCDA Entry Level Template
Open/ClosedClosed (only defined elements are allowed)
Associated with
Associated with 7 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-99draft Assessment Scales draft APSR 2.0
Used by / Uses
Used by 0 transactions and 1 template, Uses 7 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.3.10.4.3Containmentdraft ICD-O-3 Typing and Grading Observation (2.0)2015‑11‑29 17:03:18
Uses as NameVersion
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
1.3.6.1.4.1.19376.1.3.10.9.42Containmentdraft Assessment Scoring System APSR 2.0 (2.0)2016‑10‑10 11:33:36
1.3.6.1.4.1.19376.1.8.1.4.2Containmentdraft Author (2.0)2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6Containmentdraft Informant (2.0)2016‑07‑08 11:22:58
1.3.6.1.4.1.19376.1.8.1.4.7Containmentdraft Additional participant in an entry (2.0)2016‑07‑12 18:44:06
2.16.840.1.113883.10.12.324Containmentactive CDA Reference2005‑09‑07
RelationshipSpecialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54)
Example
example for use case #1, ER-Allred Score
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.4.9"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_AllredScore"/>  <code code="445104009" codeSystem="2.16.840.1.113883.6.96" displayName="Allred score"/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="201001041405-0500"/>  </effectiveTime>  <value xsi:type="PQ" value="8"/>  <interpretationCode code="RR" displayName="Reactive" codeSystem="2.16.840.1.113883.5.83"/>  <methodCode code="0114" codeSystem="2.16.840.1.113883.1.11.14079" displayName="Microscopy, Light"/>  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->
  </performer>  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->
  </author>  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->
  </informant>  <participant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (2016-07-12T18:44:06) -->
  </participant>  <specimen typeCode="SPC">
    <specimenRole classCode="SPEC">
      <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_slide_A1_ER"/>    </specimenRole>  </specimen>  <entryRelationship typeCode="SPRT">
    <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.3.10.9.42 'Assessment Scoring System APSR 2.0' (2016-10-10T11:33:36) -->
  </entryRelationship></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
 
target
psr-dataelement-99draft Assessment Scales draft APSR 2.0
@classCode
cs0 … 1FOBS
@moodCode
cs1 … 1FEVN
@negationInd
bl0 … 1 
hl7:templateId
II1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
@root
uid1 … 1F1.3.6.1.4.1.19376.1.3.10.4.4
hl7:id
II0 … *RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
hl7:code
CE (extensible)1 … 1MAssessment scale, e.g. grading by scoringPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
 CONF
@code shall be "273249006"
@codeSystem shall be "2.16.840.1.113883.6.96"
@codeSystemName shall be "SCT"
@displayName shall be "Assessment scales"
or
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.19918 ActCoverageAssessmentObservationValue (2014‑03‑26)
 Example
for use case #1
<code code="273249006" codeSystem="2.16.840.1.113883.6.96" displayName="Assessment scales (assessment scale)"/>
hl7:derivationExpr
ST0 … 1RThis optional field can be used to specify how the total score is calculated. In most cases the total score will be the sum of its components. But complex mathematical functions and/or logical operations are possible as well.PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
hl7:text
ED0 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
 Example
for use case #1
<text>Nottingham combined grad I (1 of 3)</text>
hl7:statusCode
CS1 … 1MThe observation statusCode is “ completed ” if the observation was actually performed and has produced a result in the  value  element. In other cases the status of the intended observation is “ aborted ” and the result will never come. PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
 Constraint
@code shall be "completed"
or
@code shall be "aborted"

 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (2014‑03‑26)
hl7:effectiveTime
IVL_TS1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
hl7:value
ANY1 … *Rany total value of a scoring systems, e.g. Gleason score, van Nuys score, etc., either with data type INT or with data type CD or CO PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
 Example
for use case #1, Nottingham combined grade I
<value value="1"/>
hl7:interpretationCode
CE0 … *RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)
hl7:methodCode
CE0 … *RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
@code
CONF0 … 1F0114
@codeSystem
0 … 1F2.16.840.1.113883.1.11.14079
@codeSystemName
0 … 1FHL7
@displayName
0 … 1FMicroscopy, Light
hl7:performer
II0 … 1CPerforming lab

Source: PaLM TF-3: 6.3.2.20
Contains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)		PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
 ConstraintThe performing laboratory is present at this level only if this particular observation was performed by a (subcontractor) laboratory distinct from the one issuing the rest of the observations in this organizer.
hl7:author
II0 … *CAuthor

Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.2

Contains 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11)		PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
hl7:informant
II0 … *RInformant

Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.5
Contains 1.3.6.1.4.1.19376.1.8.1.4.6 Informant (2016‑07‑08 11:22:58)		PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
hl7:participant
II0 … *RAdditional participants

Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.6
Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry (2016‑07‑12 18:44:06)		PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
Included0 … *R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
hl7:specimen
0 … *RRequired 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:entryRelationship
0 … *RContains 1.3.6.1.4.1.19376.1.3.10.9.42 Assessment Scoring System APSR 2.0 (2016‑10‑10 11:33:36)PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
@typeCode
cs1 … 1FSPRT
hl7:sequenceNumber
INT0 … 1PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
hl7:reference
0 … *RContains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
hl7:referenceRange
0 … *RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
@typeCode
cs1 … 1FREFV
hl7:observationRange
1 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
@classCode
cs0 … 1FOBS
@moodCode
cs0 … 1FEVN.CRT
hl7:code
CD0 … 1PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
@codeSystem
CONF0 … 1F2.16.840.1.113883.5.4
hl7:text
ED0 … 1PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
hl7:value
ANY0 … 1PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
hl7:interpretationCode
CE0 … 1PaLM Suppl. APSR 2.1‑3: 6.3.5.10 Assessment scales
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)