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Template Procedure Steps Section 2014‑05‑13 19:33:12

Id1.3.6.1.4.1.19376.1.8.1.2.6Effective Date2014‑05‑13 19:33:12
Statusdraft DraftVersion Label2.0
NameProcedureStepsSectionDisplay NameProcedure Steps Section
Description
The Procedure steps section contains the description of tissue dissection: representative specimens and derived specimens dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, electron microscopy, etc.) or biorepository.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.2.6
LabelPaLM Suppl. 2.1‑3: 6.3.3.7 Procedure steps section
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 5 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-23draft Procedure 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
1.3.6.1.4.1.19376.1.3.10.4.1Containmentdraft Specimen Procedure Step (2.0)2016‑07‑08 13:20:59
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" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.2.6"/>  <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008"/>  <code code="46059-2" codeSystem="2.16.840.1.113883.6.1" displayName="Special treatments and procedures section"/>  <title>PROCEDURE STEPS SECTION</title>  <!--list and hierarchy of specimens, parts, blocks and slides. Parts are here a theoretical construction for assigning gross description observations -->
  <text>
     RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)    <br/>    
PARAFFIN BLOCK NUMBER: A1.:FOUR SECTIONS FOR EACH STAIN:    <br/>    <paragraph ID="A7102400008">RIGHT BREAST FIVE CORES 8-9:00</paragraph>    <paragraph ID="block_A_1">PARAFFIN BLOCK NUMBER: A1</paragraph>    <paragraph ID="slide_A_1_HE">slide from block A1 HE stained</paragraph>    <paragraph ID="slide_A_1_ER">slide from block A1 ER
Immunohistochemistry</paragraph>    <paragraph ID="slide_A_1_PR">slide from block A1 PR
Immunohistochemistry</paragraph>    <paragraph ID="slide_A_1_EGFR">slide from block A1 EGFR (PharmDX)
Immunohistochemistry</paragraph>    <paragraph ID="slide_A_1_HER2">slide from block A1 HER2
Immunohistochemistry</paragraph>    <paragraph ID="slide_A_1_HER2_FISH">slide block from A1 HER2
FISH</paragraph>  </text>  <entry typeCode="COMP" contextConductionInd="false">
    <!-- template 1.3.6.1.4.1.19376.1.3.10.4.1 'Specimen Procedure Step' (2016-07-08T13:20:59) -->
  </entry></section>
ItemDTCardConfDescriptionLabel
hl7:section
0 … 1RPaLM Suppl. 2.1‑3: 6.3.3.7 Procedure steps section
 
target
psr-dataelement-23draft Procedure draft APSR 2.0
@classCode
cs0 … 1FDOCSECT
@moodCode
cs0 … 1FEVN
 Constraint

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

@code="46059-2"

@codeSystem="2.16.840.1.113883.6.1"

@displayName="Special treatments and procedures section" 

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

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

The section SHOULD contain as many Specimen Procedure Steps entry elements as there are procedure steps or groups thereof to be described. These entries provide the machine-readable data corresponding to the narrative block. 

hl7:templateId
II1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.7 Procedure steps section
@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.2.6
hl7:code
CE1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.7 Procedure steps section
@code
CONF1 … 1F46059-2
@codeSystem
1 … 1F2.16.840.1.113883.6.1
@codeSystemName
1 … 1FLOINC
@displayName
1 … 1FSpecial treatments and procedures section
hl7:title
ST1 … 1RThe Procedure Steps Section<title> SHALL be present. It is the local translation of the code@displayName PaLM Suppl. 2.1‑3: 6.3.3.7 Procedure steps section
hl7:text
SD.TEXT1 … 1MPaLM Suppl. 2.1‑3: 6.3.3.7 Procedure steps section
 Example
example for use case#1
<text>
   RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE
BIOPSY)  <br/>  
PARAFFIN BLOCK NUMBER: A1.:FOUR SECTIONS FOR EACH STAIN:  <br/>  <paragraph ID="A7102400008">RIGHT BREAST FIVE CORES 8-9:00</paragraph>  <paragraph ID="block_A_1">PARAFFIN BLOCK NUMBER: A1</paragraph>  <paragraph ID="slide_A_1_HE">slide from block A1 HE stained</paragraph>  <paragraph ID="slide_A_1_ER">slide from block A1 ER Immunohistochemistry</paragraph>  <paragraph ID="slide_A_1_PR">slide from block A1 PR Immunohistochemistry</paragraph>  <paragraph ID="slide_A_1_EGFR">slide from block A1 EGFR (PharmDX) Immunohistochemistry</paragraph>  <paragraph ID="slide_A_1_HER2">slide from block A1 HER2 Immunohistochemistry</paragraph>  <paragraph ID="slide_A_1_HER2_FISH">slide block from A1 HER2 FISH</paragraph></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 … *RSpecimen procedure steps 

Source: PaLM Suppl.APSR 2.0‑3:6.2.5.3
Contains 1.3.6.1.4.1.19376.1.3.10.4.1 Specimen Procedure Step (2016‑07‑08 13:20:59)		PaLM Suppl. 2.1‑3: 6.3.3.7 Procedure steps section
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl0 … 1