Template
Show index

Template TNM T-Observation 2014‑12‑02 15:54:17

Id

1.3.6.1.4.1.19376.1.3.10.9.25

Effective Date

2014‑12‑02 15:54:17

Status

draft

Draft

Version Label

2.0

Name

TNMTObservation

Display Name

TNM T-Observation

Description

Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF)

T-Observation:
The following details are provided as qualifiers:

clinical/phological
Certainty Factor
multiple tumors + multiplicity
mi-Symbol
Mucosa-level of infiltration
Submucosa-level of infiltration

Context

Parent nodes of template element with id 1.3.6.1.4.1.19376.1.3.10.9.25

Label

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

Classification

CDA Entry Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 10 concepts

Id	Name	Data Set
psr-dataelement-95	Parent ID	APSR 2.0
psr-dataelement-17	Specimen identification	APSR 2.0
psr-dataelement-67	Block ID	APSR 2.0
psr-dataelement-68	Tissue section ID	APSR 2.0
psr-dataelement-98	Specimen ID	APSR 2.0
psr-dataelement-66	Part ID	APSR 2.0
psr-dataelement-60	Clinical	APSR 2.0
psr-dataelement-61	Multiplicity	APSR 2.0
psr-dataelement-59	Postoperative	APSR 2.0
psr-dataelement-6	T-category	APSR 2.0

Used by / Uses

Used by 0 transactions and 1 template, Uses 4 templates

Used by	as	Name	Version
1.3.6.1.4.1.19376.1.3.10.4.2	Containment	UICC/AJCC TNM Staging and Grading Observation (2.0)	2014‑05‑13 15:45:13
Uses	as	Name	Version
1.3.6.1.4.1.19376.1.3.3.1.7	Containment	Laboratory Performer (2017)	2008‑08‑08
1.3.6.1.4.1.19376.1.3.10.9.1	Include	X Specimen Identified (2.0)	2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.8.1.4.2	Containment	Author (2.0)	2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6	Containment	Informant (2.0)	2016‑07‑08 11:22:58

Relationship

Specialization: template 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54)

Example

generated example

<observation negationInd="false" classCode="OBS" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.3.10.9.25"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="21899-0" codeSystem="2.16.840.1.113883.6.1"/>  <text/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20170712152936"/>  </effectiveTime>  <value xsi:type="CD" code="261663004" displayName="Tumor stage Ta (tumor staging)" codeSystem="2.16.840.1.113883.6.96">
    <qualifier>
      <name code="tnmCFactor" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="84068000" displayName="C1 - TNM certainty factor" codeSystem="2.16.840.1.113883.6.96"/>    </qualifier>    <qualifier>
      <name code="tnmCp" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="p" displayName="p" codeSystem="1.2.276.0.76.11.9"/>    </qualifier>    <qualifier>
      <name code="tnmMultiplicity" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="m" displayName="(m)" codeSystem="2.16.840.1.113883.15.6"/>    </qualifier>    <qualifier>
      <name code="tnmMucosaSymbol" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="m1" displayName="m1" codeSystem="2.16.840.1.113883.15.6"/>    </qualifier>    <qualifier>
      <name code="tnmSubmucosaSymbol" codeSystem="1.2.276.0.76.3.1.131.1.5.1"/>      <value code="sm1" displayName="sm1" codeSystem="2.16.840.1.113883.15.6"/>    </qualifier>  </value>  <performer>
    
  </performer>  <author>
    
  </author>  <informant>
    
  </informant>  
</observation>

Item

DT

Card

Conf

Description

Label

hl7:observation

0 … 1

R

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

@classCode

cs

1 … 1

F

OBS

@moodCode

cs

1 … 1

F

EVN

@negationInd

bl

0 … 1

hl7:templateId

II

1 … 1

M

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

@root

uid

1 … 1

F

1.3.6.1.4.1.19376.1.3.10.9.25

hl7:id

II

0 … *

R

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

hl7:code

CE (extensible)

1 … 1

M

the observation can be indicated either by a LOINC or Snomed code.

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

CONF

@code shall be "21899-0"

@codeSystem shall be "2.16.840.1.113883.6.1"

@codeSystemName shall be "LOINC"

or

@code shall be "78873005"

@codeSystem shall be "2.16.840.1.113883.6.96"

@codeSystemName shall be "Snomed CT"

@displayName shall be "T category (observable entity)"

hl7:text

ED

0 … 1

R

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

hl7:statusCode

1 … 1

M

The 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: 6.3.5.8 TNM

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_TS

1 … 1

M

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

hl7:value

CD (extensible)

1 … 1

R

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM


	psr-dataelement-6	T-category	APSR 2.0

CONF

The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.12 UICC T category (SCT) (2014‑05‑13 15:52:43)

or

The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.43 UICC T category (2017‑07‑07 15:06:39)

hl7:qualifier

CR (extensible)

0 … 1

R

C-Factor (Certainty)

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

Constraint

in UICC/AJCC TNM 8th edition no longer used

hl7:name

1 … 1

M

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

@codeSystem

oid

1 … 1

F

1.2.276.0.76.3.1.131.1.5.1

@code

cs

1 … 1

F

tnmCFactor

hl7:value

CD (extensible)

0 … 1

R

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

CONF

The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.20 UICC C-Factor (SCT) (2015‑06‑22 15:47:55)

or

The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.19 UICC C-Factor (2015‑11‑13 13:56:23)

hl7:qualifier

CR (extensible)

0 … 1

R

how is the T-value determined:
- clinically ("c")
-- ultrasound
-- CT
-- MR
- pathologically, postoperatively ("p")

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM


	psr-dataelement-60	Clinical	APSR 2.0
	psr-dataelement-59	Postoperative	APSR 2.0

hl7:name

1 … 1

M

clinical or pathological

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

@codeSystem

oid

1 … 1

F

1.2.276.0.76.3.1.131.1.5.1

@code

cs

1 … 1

F

tnmCp

hl7:value

CD (extensible)

0 … 1

R

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

Constraint

in APSR only "p" allowed

CONF

The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.22 TNM_Praefix_CP_UICC (2015‑11‑04 15:52:34)

hl7:qualifier

CR (extensible)

0 … 1

R

tnmMuliple :
multiple, simultaneous tumors in one organ;
here: a boolean indicator that there are multiple tumors ("m") without any numbers

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM


	psr-dataelement-61	Multiplicity	APSR 2.0

hl7:name

1 … 1

M

code for multiple tumors in one organ

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

@codeSystem

oid

1 … 1

F

1.2.276.0.76.3.1.131.1.5.1

@code

cs

1 … 1

F

tnmMultiplicity

hl7:value

CV (extensible)

0 … 1

R

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

CONF

The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.37 UICC Multiplicity (2015‑11‑06 10:44:54)

hl7:qualifier

CR (extensible)

0 … 1

R

limited to mucosa

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

hl7:name

1 … 1

M

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

@codeSystem

oid

1 … 1

F

1.2.276.0.76.3.1.131.1.5.1

@code

cs

1 … 1

F

tnmMucosaSymbol

hl7:value

CD (extensible)

0 … 1

R

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

CONF

The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.26 UICC Mucosa (2015‑11‑04 16:22:04)

hl7:qualifier

CR (extensible)

0 … 1

R

limited to mucosa and submucosa

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

hl7:name

1 … 1

M

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

@codeSystem

oid

1 … 1

F

1.2.276.0.76.3.1.131.1.5.1

@code

cs

1 … 1

F

tnmSubmucosaSymbol

hl7:value

CD (extensible)

0 … 1

R

PaLM Suppl. APSR 2.1‑3: 6.3.5.8 TNM

CONF

The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.27 UICC Submucosa (2015‑11‑04 16:23:24)

hl7:performer

II

0 … 1

C

Performing 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: 6.3.5.8 TNM

hl7:author

II

0 … *

C

Author

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: 6.3.5.8 TNM

hl7:informant

II

0 … *

R

Informant

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: 6.3.5.8 TNM

Included

1 … *

M

from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)

hl7:specimen

1 … *

M

Required 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


	psr-dataelement-17	Specimen identification	APSR 2.0

@typeCode

cs

0 … 1

F

SPC

hl7:specimenRole

1 … 1

M

PaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified

@classCode

cs

0 … 1

F

SPEC

hl7:id

II

1 … 1

R

Specimen ID, coming from the LIS

PaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified


	psr-dataelement-95	Parent ID	APSR 2.0
	psr-dataelement-67	Block ID	APSR 2.0
	psr-dataelement-68	Tissue section ID	APSR 2.0
	psr-dataelement-98	Specimen ID	APSR 2.0
	psr-dataelement-66	Part ID	APSR 2.0