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Template Clinical Information Section 2014‑05‑13 14:38:08

Id1.3.6.1.4.1.19376.1.8.1.2.1Effective Date2014‑05‑13 14:38:08
Statusdraft DraftVersion Label2.0
NameClinicalInformationSectionDisplay NameClinical Information Section
Description
The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, reason for anatomic pathology procedure, clinical laboratory data, information about specimens collected in this case (including target site, performer, specimen type, specimen(s) clinical description, and tumor site in case of a cancer).
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.1
LabelPaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 8 concepts
IdNameData Set
psr-dataelement-4draft Pathologist draft APSR 2.0
psr-dataelement-18draft Address draft APSR 2.0
psr-dataelement-79draft Device draft APSR 2.0
psr-dataelement-5draft Name draft APSR 2.0
psr-dataelement-43draft Clinical Problem draft APSR 2.0
psr-dataelement-42draft History of Present Illness draft APSR 2.0
psr-dataelement-40draft Clinical Information draft APSR 2.0
psr-dataelement-41draft Reason for Referral draft APSR 2.0
Used by / Uses
Used by 1 transaction and 1 template, Uses 5 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
1.3.6.1.4.1.19376.1.8.1.1.1Containmentdraft Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
Uses as NameVersion
1.3.6.1.4.1.19376.1.5.3.1.3.1Containmentactive IHE Reason for Referral Section (2014)2016‑09‑26 07:58:18
1.3.6.1.4.1.19376.1.5.3.1.3.4Containmentactive IHE History of Present Illness Section (2014)2013‑01‑31
1.3.6.1.4.1.19376.1.5.3.1.3.6Containmentactive IHE Active Problems Section (2014)2015‑10‑05 16:02:07
1.3.6.1.4.1.19376.1.8.1.3.6Containmentdraft Problem Organizer (2.0)2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.8.1.4.2Includedraft Author (2.0)2016‑06‑21 14:02:11
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
Example
generated example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.1"/>  <code code="22636-5" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report relevant history"/>  <title>CLINICAL INFORMATION SECTION</title>  <text/>  <languageCode/>  <entry xsi:type="ANY" typeCode="COMP" contextConductionInd="true">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->
  </entry>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->
  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.1 'IHE Reason for Referral Section' (2016-09-26T07:58:18) -->
  </component>  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.4 'History of Present Illness Section' (2013-01-31T00:00:00)
-->
  </component>  <component>
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.6 'IHE Active Problems Section' (2015-10-05T16:02:07) -->
  </component></section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … 1RPaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
 
target
psr-dataelement-40draft Clinical Information draft APSR 2.0
@classCode
cs0 … 1FDOCSECT
@moodCode
cs0 … 1FEVN
 Constraint

This section SHALL contain a code element populated with these attributes:

@code="22636-5" 

@codeSystem="'2.16.840.1.113883.6.1" 

@displayName=" Pathology report relevant history”  

This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.

The section SHOULD contain as many Problem Organizer entry elements as there are problems (or groups thereof) to be described. These entries provide the machine-readable data corresponding to the narrative block.

This section MAY contain a number of elements component/section introducing sub-sections, each of these sub-sections providing a particular type of clinical information.

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.

hl7:templateId
II1 … 1RPaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.1
hl7:code
CE1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
@code
CONF1 … 1F22636-5
@codeSystem
1 … 1F2.16.840.1.113883.6.1
@codeSystemName
1 … 1FLOINC
@displayName
1 … 1FPathology report relevant history
hl7:title
ST1 … 1RThe Clinical Information Section<title> SHALL be present. It is the local translation of the code@displayName PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
 Example<title>CLINICAL INFORMATION</title>
hl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
 Example<text> Tissue submitted: left breast biopsy and apical axillary tissue </text>
hl7:languageCode
CS0 … 1PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (2014‑03‑26)
hl7:entry
ANY0 … *RProblem organizer
Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (2015‑08‑13 10:24:55)		PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
@typeCode
cs0 … 1FCOMP
@contextConductionInd
bl0 … 1Ftrue
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11)
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2
 Constraint

This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document.


hl7:author
0 … *CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
 
target
psr-dataelement-4draft Pathologist draft APSR 2.0
psr-dataelement-79draft Device draft APSR 2.0
@typeCode
cs1 … 1FAUT
 Example
author is a person
<author typeCode="AUT" contextControlCode="OP">
  <time value="201306101654"/>  <assignedAuthor classCode="ASSIGNED">
    <!-- ... -->
  </assignedAuthor></author>
hl7:templateId
1 … 1MPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.2
hl7:time
TS1 … 1MThe authoring time is the date & time that this author contributed to the document. It SHALL be provided.PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:assignedAuthor
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
@classCode
cs0 … 1FASSIGNED
hl7:id
II1 … *MPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:addr
AD1 … *MPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
 
target
psr-dataelement-18draft Address draft APSR 2.0
hl7:telecom
TEL1 … *MPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
Choice1 … 1
The author is either an assigned person or an authoring device.
Elements to choose from:
  • hl7:assignedPerson
  • hl7:assignedAuthoringDevice
hl7:assignedPerson
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
 
target
psr-dataelement-5draft Name draft APSR 2.0
Included1 … 1R from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
The name(s) SHALL be given.
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
hl7:name
PN1 … 1RCDAPerson
hl7:assignedAuthoringDevice
0 … 1CPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
@classCode
cs0 … 1FDEV
@determinerCode
cs0 … 1FINSTANCE
hl7:manufacturerModelName
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:softwareName
SC0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:code
CE0 … 1RPaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
hl7:representedOrganization
0 … 1PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author
 Example
represented organization for author as a device
<representedOrganization classCode="ORG" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name></representedOrganization>
Included0 … 1 from 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)
The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given.
@classCode
cs0 … 1FORG
@determinerCode
cs0 … 1FINSTANCE
hl7:id
II0 … 1CDAOdotstion
hl7:name
ON0 … 1CDAOdotstion
hl7:telecom
TEL0 … 1CDAOdotstion
hl7:addr
AD0 … 1CDAOdotstion
hl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassCDAOdotstion
hl7:asOrganizationPartOf
0 … 1CDAOdotstion
@classCode
cs0 … 1FPART
hl7:id
II0 … *RCDAOdotstion
hl7:code
CE0 … 1CDAOdotstion
 CONF
shall be drawn from concept domain "RoleCode"
hl7:statusCode
CS0 … 1CDAOdotstion
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC)
hl7:effectiveTime
IVL_TS0 … 1CDAOdotstion
hl7:wholeOrganization
0 … 1CDAOdotstion
@classCode
cs0 … 1FORG
@determinerCode
cs0 … 1FINSTANCE
hl7:id
II0 … *CDAOdotstion
hl7:name
ON0 … *CDAOdotstion
hl7:telecom
TEL0 … *CDAOdotstion
hl7:addr
AD0 … *CDAOdotstion
hl7:standardIndustryClassCode
CE0 … 1SHALL be chosen from domain OrganizationIndustryClassCDAOdotstion
hl7:component
0 … 1Subsection

Source: PCC TF-2: 6.3.3.1.1
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.1 IHE Reason for Referral Section (2016‑09‑26 07:58:18)		PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
 
target
psr-dataelement-41draft Reason for Referral draft APSR 2.0
hl7:component
0 … 1Subsection


Source: PCC TF-2: 6.3.3.2.1
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 IHE History of Present Illness Section (2013‑01‑31)		PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
 
target
psr-dataelement-42draft History of Present Illness draft APSR 2.0
hl7:component
0 … 1Subsection

Source: PCC TF-2: 6.3.3.2.3
Contains 1.3.6.1.4.1.19376.1.5.3.1.3.6 IHE Active Problems Section (2015‑10‑05 16:02:07)		PaLM Suppl. 2.1‑3: 6.3.3.1 Clinical information section
 
target
psr-dataelement-43draft Clinical Problem draft APSR 2.0