DiagnosticConclusionSection

Template Diagnostic Conclusion Section 2014‑05‑13 19:31:26

1.3.6.1.4.1.19376.1.8.1.2.5

Effective Date

2014‑05‑13 19:31:26

Status

Draft

Version Label

2.0

Name

DiagnosticConclusionSection

Display Name

Diagnostic Conclusion Section

Description

The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.

Context

Parent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.5

Label

PaLM Suppl. 2.1‑3: 6.3.3.6 Diagnostic conclusion section

Classification

CDA Section Level Template

Open/Closed

Open (other than defined elements are allowed)

Associated with

Associated with 7 concepts

Id	Name	Data Set
psr-dataelement-4	Pathologist	APSR 2.0
psr-dataelement-18	Address	APSR 2.0
psr-dataelement-79	Device	APSR 2.0
psr-dataelement-5	Name	APSR 2.0
psr-dataelement-45	Diagnostic conclusion	APSR 2.0
psr-dataelement-3	Tumor formula (TNM)	APSR 2.0
psr-dataelement-54	Tumor classification (ICD-O-3)	APSR 2.0

Used by / Uses

Used by 1 transaction and 1 template, Uses 3 templates

Used by	as	Name	Version
2.16.840.1.113883.2.6.60.6.4.2	Transaction	CDA Document Anatomic Pathology Structured Report 2015 (2.0)	2015‑10‑23 10:32:36
1.3.6.1.4.1.19376.1.8.1.1.1	Containment	Anatomic Pathology Structured Report Content Module (2.0)	2014‑05‑13 11:57:57
Uses	as	Name	Version
1.3.6.1.4.1.19376.1.3.10.4.5	Containment	Update Information Organizer (2.0)	2017‑11‑14 15:22:14
1.3.6.1.4.1.19376.1.8.1.3.6	Containment	Problem Organizer (2.0)	2015‑08‑13 10:24:55
1.3.6.1.4.1.19376.1.8.1.4.2	Include	Author (2.0)	2016‑06‑21 14:02:11

Relationship

Specialization: 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="1.3.6.1.4.1.19376.1.8.1.2.5"/>  <code code="22637-3" displayName="Pathology report final diagnosis" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <title>DIAGNOSTIC CONCLUSION SECTION</title>  <text>
    <paragraph> A1. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)</paragraph>
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>
ICD-O-CLASSIFICATION: C50.3 M8500/31    <br/>
IN-SITU CARCINOMA: EQUIVOCAL.    <br/>
BREAST CANCER BIOMARKER STUDIES:
    <list>
      <item>PARAFFIN BLOCK NUMBER: A1.</item>      <item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8, Percentage stained tumor cells = 85%, 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>  
  <entry>
    
  </entry>  <entry>
    
  </entry></section>

Item

Card

Conf

Description

Label

hl7:section

1 … 1

PaLM Suppl. 2.1‑3: 6.3.3.6 Diagnostic conclusion section


psr-dataelement-45	Diagnostic conclusion	APSR 2.0
psr-dataelement-3	Tumor formula (TNM)	APSR 2.0
psr-dataelement-54	Tumor classification (ICD-O-3)	APSR 2.0

@classCode

1 … 1

DOCSECT

@moodCode

1 … 1

EVN

Constraint

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

@code="22637-3"

@codeSystem="2.16.840.1.113883.6.1"

@displayName="Pathology report diagnosis"

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

The section SHALL contain as many Problem Organizer entry elements as there are problems or groups thereof investigated. Each entry provides machine-readable data.

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

1 … 1

PaLM Suppl. 2.1‑3: 6.3.3.6 Diagnostic conclusion section

@root

uid

1 … 1

1.3.6.1.4.1.19376.1.8.1.2.5

hl7:code

1 … 1

PaLM Suppl. 2.1‑3: 6.3.3.6 Diagnostic conclusion section

@code

CONF

1 … 1

22637-3

@codeSystem

1 … 1

2.16.840.1.113883.6.1

@codeSystemName

1 … 1

LOINC

@displayName

1 … 1

'Pathology report diagnosis

hl7:title

1 … 1

The Diagnostic Conclusion Section<title> SHALL be present. It is the local translation of the code@displayName

PaLM Suppl. 2.1‑3: 6.3.3.6 Diagnostic conclusion section

Example

<hl7:title>Pathology Final Diagnosis</hl7:title>

hl7:text

SD.TEXT

1 … 1

PaLM Suppl. 2.1‑3: 6.3.3.6 Diagnostic conclusion section

Example

example for use case#1

<text>
  <paragraph> A1. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)
</paragraph>
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>
ICD-O-CLASSIFICATION: C50.3 M8500/31  <br/>
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, Percentage stained tumor cells = 85%, 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>

Included

0 … *

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 … *

PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author


psr-dataelement-4	Pathologist	APSR 2.0
psr-dataelement-79	Device	APSR 2.0

@typeCode

1 … 1

AUT

Example

author is a person

hl7:templateId

1 … 1

PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author

@root

uid

1 … 1

1.3.6.1.4.1.19376.1.8.1.4.2

hl7:time

1 … 1

The 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 … 1

PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author

@classCode

0 … 1

ASSIGNED

hl7:id

1 … *

PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author

hl7:addr

1 … *

PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author


	psr-dataelement-18	Address	APSR 2.0

hl7:telecom

TEL

1 … *

PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author

Choice

1 … 1

The author is either an assigned person or an authoring device.

Elements to choose from:

hl7:assignedPerson
hl7:assignedAuthoringDevice

hl7:assignedPerson

0 … 1

PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author


	psr-dataelement-5	Name	APSR 2.0

Included

1 … 1

from 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
The name(s) SHALL be given.

@classCode

0 … 1

PSN

@determinerCode

0 … 1

INSTANCE

hl7:name

1 … 1

CDAPerson

hl7:assignedAuthoringDevice

0 … 1

PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author

@classCode

0 … 1

DEV

@determinerCode

0 … 1

INSTANCE

hl7:manufacturerModelName

0 … 1

PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author

hl7:softwareName

0 … 1

PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author

hl7:code

0 … 1

PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author

hl7:representedOrganization

0 … 1

PaLM Suppl.APSR 2.0‑3:6.3.5.1 Author

Example

represented organization for author as a device

Included

0 … 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

0 … 1

ORG

@determinerCode

0 … 1

INSTANCE

hl7:id

0 … 1

CDAOtion

hl7:name

0 … 1

CDAOtion

hl7:telecom

TEL

0 … 1

CDAOtion

hl7:addr

0 … 1

CDAOtion

hl7:standardIndustryClassCode

0 … 1

SHALL be chosen from domain OrganizationIndustryClass

CDAOtion

hl7:asOrganizationPartOf

0 … 1

CDAOtion

@classCode

0 … 1

PART

hl7:id

0 … *

CDAOtion

hl7:code

0 … 1

CDAOtion

CONF

shall be drawn from concept domain "RoleCode"

hl7:statusCode

0 … 1

CDAOtion

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15999 RoleStatus (DYNAMIC)

hl7:effectiveTime

IVL_TS

0 … 1

CDAOtion

hl7:wholeOrganization

0 … 1

CDAOtion

@classCode

0 … 1

ORG

@determinerCode

0 … 1

INSTANCE

hl7:id

0 … *

CDAOtion

hl7:name

0 … *

CDAOtion

hl7:telecom

TEL

0 … *

CDAOtion

hl7:addr

0 … *

CDAOtion

hl7:standardIndustryClassCode

0 … 1

SHALL be chosen from domain OrganizationIndustryClass

CDAOtion

hl7:entry

0 … 1

Source: PaLM Suppl. APSR 2.0-3: 6.2.5.4
Contains 1.3.6.1.4.1.19376.1.3.10.4.5 Update Information Organizer (2017‑11‑14 15:22:14)

PaLM Suppl. 2.1‑3: 6.3.3.6 Diagnostic conclusion section

@typeCode

1 … 1

COMP

@contextConductionInd

0 … 1

true

Constraint

if ClinicalDocument.versionNumber > 1

hl7:entry

1 … *

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: 6.3.3.6 Diagnostic conclusion section

@typeCode

1 … 1

COMP

@contextConductionInd

0 … 1

true

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Template Diagnostic Conclusion Section 2014‑05‑13 19:31:26