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Template Microscopic Observation Section 2014‑05‑13 14:25:17

Id1.3.6.1.4.1.19376.1.8.1.2.4Effective Date2014‑05‑13 14:25:17
Statusdraft DraftVersion Label2.0
NameMicroscopySectionDisplay NameMicroscopic Observation Section
Description
The Microscopic Observation section contains optionally the histopathologic findings of the case and of all of the derived specimens. This section should be used to record the results of histochemical and immunohistochemical stains and of image-based molecular methods.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.4
LabelPaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 6 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-16draft microscopic observation text draft APSR 2.0
psr-dataelement-15draft Microscopic observation draft APSR 2.0
Used by / Uses
Used by 1 transaction and 1 template, Uses 2 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
1.3.6.1.4.1.19376.1.8.1.3.6Containmentdraft 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
example from use case #1
<section classCode="DOCSECT">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.4"/>  <code code="22635-7" displayName="Pathology report microscopic observation" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <title>MICROSCOPIC OBSERVATION SECTION</title>  <!-- Text: Human-readable part -->
  <text>
     INVASIVE ADENOCARCINOMA OF THE BREAST.    <br/>    
HISTOLOGIC TYPE: DUCTAL.    <br/>    
NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3.
    <list>
      <item>TUBULE FORMATION SCORE: 2.</item>      <item>NUCLEAR PLEOMORPHISM SCORE: 2.</item>      <item>MITOTIC RATE SCORE: 1.</item>    </list>    
IN-SITU CARCINOMA: EQUIVOCAL.    <br/>    <br/>    
BREAST CANCER BIOMARKER STUDIES:
    <list>
      <item>PARAFFIN BLOCK NUMBER: A1.</item>      <item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8, Allred Percentage Score = 5, Allred Staining Score = 3).</item>      <item>PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED SCORE = 8).</item>      <item>DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.</item>      <item>HER2/NEU IMMUNOHISTOCHEMISTRY: EQUIVOCAL (2+) FOR OVEREXPRESSION OF HER2/NEU ONCOPROTEIN.</item>      <item>HER2/NEU FISH RESULTS: NOT AMPLIFIED.</item>    </list>  </text></section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … 1RPaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section
 
target
psr-dataelement-15draft Microscopic observation draft APSR 2.0
 Constraint

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

@code="22635-7"

@codeSystem="2.16.840.1.113883.6.1"

@displayName="Pathology report microscopic observation" 

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

This section does not contain any subsections. 

hl7:templateId
II1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section
@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.4
hl7:code
CE1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section
@code
CONF1 … 1F22635-7
@codeSystem
1 … 1F2.16.840.1.113883.6.1
@codeSystemName
1 … 1FLOINC
@displayName
1 … 1FPathology report microscopic observation
hl7:title
ST1 … 1RThe Microscopic Observation Section<title> SHALL be present. It is the local translation of the code@displayName PaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section
 Example<title>MICROSCOPIC OBSERVATION SECTION</title>
hl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.4 Microscopic observation section
 
target
psr-dataelement-16draft microscopic observation text draft APSR 2.0
 Example
example from use case#1
<text>
   INVASIVE ADENOCARCINOMA OF THE BREAST.  <br/>  
HISTOLOGIC TYPE: DUCTAL.  <br/>  
NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3.
  <list>
    <item>TUBULE FORMATION SCORE: 2.</item>    <item>NUCLEAR PLEOMORPHISM SCORE: 2.</item>    <item>MITOTIC RATE SCORE: 1.</item>  </list>  
IN-SITU CARCINOMA: EQUIVOCAL.  <br/>  <br/>  
BREAST CANCER BIOMARKER STUDIES:
  <list>
    <item>PARAFFIN BLOCK NUMBER: A1.</item>    <item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED
SCORE = 8, Allred Percentage Score = 5, Allred Staining Score = 3).</item>    <item>PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED
SCORE = 8).</item>    <item>DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR
EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.</item>    <item>HER2/NEU IMMUNOHISTOCHEMISTRY: EQUIVOCAL (2+) FOR OVEREXPRESSION
OF HER2/NEU ONCOPROTEIN.</item>    <item>HER2/NEU FISH RESULTS: NOT AMPLIFIED.</item>  </list></text>
Included0 … *C from 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11)
Author

Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2
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:entry
0 … *RProblem organizer entry

Source: PaLM Suppl. APSR 2.0-3: 6.2.5.2
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: 6.3.3.4 Microscopic observation section
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl0 … 1Ftrue