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Template Problem Organizer 2015‑08‑13 10:24:55

Id1.3.6.1.4.1.19376.1.8.1.3.6Effective Date2015‑08‑13 10:24:55
Statusdraft DraftVersion Label2.0
NameProblemOrganizerDisplay NameProblem Organizer
Description
Template CDA Organizer (prototype, directly derived from POCD_RM000040 MIF)

The problem organizer groups the various observations performed and assocciated images to investigate on a single problem identified on one or more specimens  


ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.3.6
LabelPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 8 concepts
IdNameData Set
psr-dataelement-95draft Parent ID draft APSR 2.0
psr-dataelement-17draft Specimen identification draft APSR 2.0
psr-dataelement-67draft Block ID draft APSR 2.0
psr-dataelement-68draft Tissue section ID draft APSR 2.0
psr-dataelement-98draft Specimen ID draft APSR 2.0
psr-dataelement-66draft Part ID draft APSR 2.0
psr-dataelement-39draft Problem Organizer draft APSR 2.0
psr-dataelement-86draft Problem ID draft APSR 2.0
Used by / Uses
Used by 1 transaction and 7 templates, Uses 11 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
1.3.6.1.4.1.19376.1.3.10.3.1Containmentdraft Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.1.1linkdraft Anatomic Pathology Structured Report Content Module (2.0)2014‑05‑13 11:57:57
1.3.6.1.4.1.19376.1.8.1.2.1Containmentdraft Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2Containmentdraft Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3Containmentdraft Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4Containmentdraft Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5Containmentdraft Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.1.6Containmentactive Laboratory Observation (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.3.1.7Containmentactive Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.10.9.1Includedraft X Specimen Identified (2.0)2014‑12‑22 15:54:30
1.3.6.1.4.1.19376.1.5.3.1.4.2Containmentactive IHE Comment Entry (2014)2013‑12‑20
1.3.6.1.4.1.19376.1.8.1.4.2Containmentdraft Author (2.0)2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.6Containmentdraft Informant (2.0)2016‑07‑08 11:22:58
1.3.6.1.4.1.19376.1.8.1.4.7Containmentdraft Additional participant in an entry (2.0)2016‑07‑12 18:44:06
1.3.6.1.4.1.19376.1.8.1.4.9Containmentdraft AP Observation Entry (2.0)2014‑05‑14 17:09:54
1.3.6.1.4.1.19376.1.8.1.4.10Containmentdraft Embedded Image2016‑06‑22 16:08:01
2.16.840.1.113883.10.12.307Containmentactive CDA RegionOfInterest2005‑09‑07
2.16.840.1.113883.10.12.324Containmentactive CDA Reference2005‑09‑07
RelationshipSpecialization: template 2.16.840.1.113883.10.12.305 CDA Organizer (2005‑09‑07)
ref
ad1bbr-
Example
generated example
<organizer classCode="BATTERY" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.3.6"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">
    <qualifier>
      <name code="116677004" codeSystem="2.16.840.1.113883.6.96" displayName=" Associated topography (attribute)"/>      <value nullFlavor="cs" code="all children of "362981000"" codeSystem="2.16.840.1.113883.6.96" displayName="all values from 91723000 (Anatomical structure)"/>    </qualifier>  </code>  <component typeCode="COMP">
    <observation>
      <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem">
        <value code="115597007" displayName="Description of specimen character (procedure)" codeSystem="2.16.840.1.113883.6.96"/>      </code>    </observation>  </component>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20170131165954"/>  </effectiveTime>  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) -->
  </author>  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Header&Body) APSR2' (2016-07-08T11:22:58) -->
  </informant>  <participant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (2016-07-12T18:44:06) -->
  </participant>  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'Laboratory Performer' (2008-08-08T00:00:00) -->
  </performer>  <!-- include template 1.3.6.1.4.1.19376.1.3.10.9.1 'X Specimen Identified' (2014-12-22T15:54:30) 0..* R -->
  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' (2016-06-22T16:08:01) -->
  </component>  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' (2005-09-07T00:00:00) -->
  </component>  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.4.2 'IHE Comment Entry' (2013-12-20T00:00:00) -->
  </component>  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (2014-05-14T17:09:54) -->
  </component>  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.3.1.6 'Laboratory Observation' (2008-08-08T00:00:00) -->
  </component>  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
  </reference></organizer>
Example
example for use case #1, problem: invasive breast cancer
<organizer classCode="BATTERY" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.3.6"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_Problem1"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="201001041605-0500"/>  </effectiveTime>  <!--The problem is expressed by the result of the observation having the same code as organizer/code-->
  <component>
    <observation classCode="OBS" moodCode="EVN">
      <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>      <value code="C50.9" codeSystem="2.16.840.1.113883.6.3" displayName="Malignant neoplasm of breast, unspecified" codeSystemDisplayName="ICD-10"/>    </observation>  </component>  <component typeCode="COMP" contextConductionInd="true">
    <sequenceNumber value="1"/>    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (2014-05-14T17:09:54) -->
  </component>  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) -->
  </reference></organizer>
ItemDTCardConfDescriptionLabel
hl7:organizer
0 … *RProblem organizer groups the observations and images investigating a single problem  related to one or more specimensPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
 
target
psr-dataelement-39draft Problem Organizer draft APSR 2.0
@classCode
cs1 … 1FBATTERY
@moodCode
cs1 … 1FEVN
hl7:templateId
II1 … 1MPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.3.6
hl7:id
II0 … *RPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
 
target
psr-dataelement-86draft Problem ID draft APSR 2.0
hl7:code
CD (required)0 … 1RProblem
PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
@code
CONF0 … 1F75326-9
@codeSystem
0 … 1F2.16.840.1.113883.6.1
@codeSystemName
0 … 1FLOINC
@displayName
0 … 1FProblem
hl7:statusCode
CS (required)1 … 1MThe status of the organizer is  "completed"  if the battery of observations for this problem has been performed. It is  "aborted"  in case some of the intended observations could not be achieve and have been aborted, and appear as such below the organizer. PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
 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_TS1 … 1MOrganizer time.
The period of time (possibly reduced to a point in time) during which the information was collected and assembled. 		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
hl7:author
0 … *CAuthor

Source: PaLM 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. 2.1‑3: 6.3.4.2 Problem organizer
 ConstraintThe author SHALL be present if it is different from the main author of the report. For instance the author could be the ordering physician contributing to the Clinical Information section, inside a report authored by the pathologist.
hl7:informant
0 … *RInformant

The informant is an actor (person and organization) who provided some of the clinical information carried by this organizer.


Source: PaLM 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. 2.1‑3: 6.3.4.2 Problem organizer
hl7:participant
0 … *RTranscriptionist, Device, Responsible, Validator


Source: PaLM Suppl. APSR 2.0-3: 6.3.6.6
Contains 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry (2016‑07‑12 18:44:06)		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
 ConstraintparticipationType "ENT", "DEV", "RESP", "AUTHEN"
hl7:performer
0 … 1CPerforming lab.
The performing laboratory is present at this level only if this particular problem on this particular specimen was investigated by a (subcontractor) distinct laboratory from the one issuing the consolidated report

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. 2.1‑3: 6.3.4.2 Problem organizer
Included0 … *R from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Specimen identification outside an AP observation for differentiating or restituting the problem type

Source: PaLM Suppl. APSR 2.0-3: 6.3.6.9
hl7:specimen
0 … *RRequired 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
 
target
psr-dataelement-17draft Specimen identification draft APSR 2.0
@typeCode
cs0 … 1FSPC
hl7:specimenRole
1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified
@classCode
cs0 … 1FSPEC
hl7:id
II1 … 1RSpecimen ID, coming from the LISPaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified
 
target
psr-dataelement-95draft Parent ID draft APSR 2.0
psr-dataelement-67draft Block ID draft APSR 2.0
psr-dataelement-68draft Tissue section ID draft APSR 2.0
psr-dataelement-98draft Specimen ID draft APSR 2.0
psr-dataelement-66draft Part ID draft APSR 2.0
hl7:component
0 … 1RCoding of the Problem reportedPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
@typeCode
cs1 … 1FCOMP
hl7:observation
0 … 1RPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
hl7:code
CD (extensible)1 … 1RPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
@code
CONF0 … 1F75326-9
@codeSystem
0 … 1F2.16.840.1.113883.6.1
@codeSystemName
0 … 1FLOINC
@displayName
0 … 1FProblem
hl7:qualifier
CR0 … *ROptional qualifier for separate problems with identical problem type in one specimen, e.g. a urothelial bladder cancer Invasive cancer) and a prostate cancer (invasive cancer) in one cystoprostatectomy specimen. The anatomic structure is able to differentiate.PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
 Example
Problem in urinary bladder in cystoprostatectomy specimen
<qualifier>
  <name code="116677004" codeSystem="2.16.840.1.113883.6.96" displayName="Associated topography (attribute)" codeSystemName="SNOMED-CT"/>  <value code="302512001" codeSystem="2.16.840.1.113883.6.96" displayName=" Entire urinary bladder (body structure)" codeSystemName="SNOMED-CT"/></qualifier>
hl7:name
CV0 … 1RPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
@code
cs1 … 1F116677004
@codeSystem
oid1 … 1F2.16.840.1.113883.6.96
@displayName
st1 … 1F Associated topography (attribute)
hl7:value
CD (extensible)0 … *RPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
@code
CONF0 … 1F<< 91723000
@codeSystem
0 … 1F2.16.840.1.113883.6.96
@codeSystemName
0 … 1FSNOMED-CT
@displayName
0 … 1Fall values from Anatomical structure
hl7:value
CE (extensible)0 … 1RCode of the problem reportedPaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
 CONF
@code shall be "any_code"
@codeSystem shall be "2.16.840.1.113883.6.3"
@codeSystemName shall be "any_code"
@displayName shall be "ICD-10"
or
The value of @code should be drawn from value set 1.3.6.1.4.1.19376.1.3.11.7 Problem Type (2016‑07‑11 09:52:19)
hl7:component
0 … *RAny kind of AP observation, for complex observations, e.g. for TNM, ICD-O-3, or Assessment scales, the appropriate templates may be used.

Source: PaLM Suppl. APSR 2.0-3: 6.3.6.7
Contains 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54)		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl0 … 1Ftrue
hl7:sequenceNumber
INT0 … 1PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
hl7:component
0 … *CLaboratory observation
Contains 1.3.6.1.4.1.19376.1.3.1.6 Laboratory Observation (2008‑08‑08)		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl0 … 1Ftrue
hl7:sequenceNumber
INT0 … 1PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
hl7:component
0 … *REmbedded image

This organizer may carry an image focusing on the problem, either directly embedded or encapsulated within a region of interest.


Contains 1.3.6.1.4.1.19376.1.8.1.4.10 Embedded Image (2016‑06‑22 16:08:01)		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
@typeCode
cs0 … 1FCOMP
@contextConductionInd
bl0 … 1Ftrue
 Constraint[@classCode="ROIOVL" and moodCode="EVN"]
hl7:sequenceNumber
INT0 … 1PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
hl7:component
0 … *RRegion of interest

This organizer may carry an image focusing on the problem, either directly embedded or encapsulated within a region of interest.

In the latter case by an entryRelationship @typeCode="SUBJ"


Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (2005‑09‑07)		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl0 … 1Ftrue
 Constraint[@classCode="ROIOVL" and moodCode="EVN"]
hl7:sequenceNumber
INT0 … 1PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
hl7:component
0 … *RGeneral comment on this particular problem 

Source: PCC TF-2: 6.3.4.6
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20)		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
@typeCode
cs1 … 1FCOMP
@contextConductionInd
bl0 … 1Ftrue
hl7:sequenceNumber
INT0 … 1PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer
hl7:reference
0 … *RReference to an external document, or to external organizers, or to external observations, e.g. concerning molecular pathology or  genetic testing report
Contains 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07)		PaLM Suppl. 2.1‑3: 6.3.4.2 Problem organizer