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Template AP Observation Entry 2014‑05‑14 17:09:54

Id1.3.6.1.4.1.19376.1.8.1.4.9Effective Date2014‑05‑14 17:09:54
Statusdraft DraftVersion Label2.0
NameAPObservationEntryDisplay NameAP Observation Entry
Description
This content module is usable within a Problem organizer.

The “AP Observation” generic template is usable for all AP observations, including ancillary techniques. 

An AP observation has a status and an effective time, may describe various participants (persons, devices, organizations), may have a number of additional properties (method, interpretation, text), and may contain embedded images, comments, and sub-observations, which are also AP observations.

ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.8.1.4.9
LabelPaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 9 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-47draft ObservationReport draft APSR 2.0
psr-dataelement-57draft Scoring systems draft APSR 2.0
psr-dataelement-65draft Generic AP observation draft APSR 2.0
Used by / Uses
Used by 1 transaction and 8 templates, Uses 10 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
1.3.6.1.4.1.19376.1.3.10.3.1linkdraft 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
1.3.6.1.4.1.19376.1.8.1.2.1linkdraft Clinical Information Section (2.0)2014‑05‑13 14:38:08
1.3.6.1.4.1.19376.1.8.1.2.2linkdraft Intraoperative Observation Section (2.0)2014‑05‑13 19:29:16
1.3.6.1.4.1.19376.1.8.1.2.3linkdraft Macroscopic Observation Section (2.0)2014‑05‑13 11:57:09
1.3.6.1.4.1.19376.1.8.1.2.4linkdraft Microscopic Observation Section (2.0)2014‑05‑13 14:25:17
1.3.6.1.4.1.19376.1.8.1.2.5linkdraft Diagnostic Conclusion Section (2.0)2014‑05‑13 19:31:26
1.3.6.1.4.1.19376.1.8.1.3.6Containmentdraft Problem Organizer (2.0)2015‑08‑13 10:24:55
Uses as NameVersion
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 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
Example
Observation example for use case #1, estrogen receptor
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="1.3.6.1.4.1.19376.1.8.1.4.9"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_ER"/>  <code code="16112-5" codeSystem="2.16.840.1.113883.6.1" displayName="Estrogen receptor [Interpretation] in Tissue"/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="201001041405-0500"/>  </effectiveTime>  <value xsi:type="CD" code="416053008" displayName="Estrogen receptor positive tumor (disorder)" codeSystem="2.16.840.1.113883.6.96"/>  <methodCode code="0107" displayName="Microscopy" codeSystem="2.16.840.1.113883.5.84"/>  <performer>
    <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'CDA Performer IHE (Body)' (dynamic) -->
  </performer>  <author>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) -->
  </author>  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Body) APSR2' (dynamic) -->
  </informant>  <participant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (dynamic) -->
  </participant>  <entryRelationship xsi:type="" typeCode="COMP">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' -->
  </entryRelationship>  <entryRelationship xsi:type="" typeCode="COMP">
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' -->
  </entryRelationship>  <entryRelationship xsi:type="" typeCode="COMP">
    <!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' -->
  </entryRelationship>  <specimen typeCode="SPC">
    <specimenRole classCode="SPEC">
      <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_slide_A1_ER"/>    </specimenRole>  </specimen>  <reference>
    <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (dynamic) -->
  </reference></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
0 … *RPaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
 
target
psr-dataelement-47draft ObservationReport draft APSR 2.0
psr-dataelement-57draft Scoring systems draft APSR 2.0
psr-dataelement-65draft Generic AP observation draft APSR 2.0
@classCode
cs1 … 1FOBS
@moodCode
cs1 … 1FEVN
@negationInd
bl0 … 1 
hl7:templateId
II1 … 1MPaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.9
hl7:id
II0 … *RPaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
hl7:code
CE (extensible)1 … 1MThe Anatomic pathology observation code should be taken from a reference terminology, preferably the LOINC terminology. National terminologies may be used.PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
@code
CONF1 … 1Feach_code_for_observable_entities_or_a_specific_procedure
@codeSystem
1 … 1F2.16.840.1.113883.6.1
@codeSystemName
1 … 1FLOINC
@displayName
1 … 1Fsee_above
 Example<code code="59847-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Histology and Behavior ICD-O-3"/>
hl7:text
ED0 … 1RNarrative text about the observationPaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
hl7:statusCode
CS (required)1 … 1MThe observation statusCode is “completed” if the observation was actually performed and has produced a result in the valueelement. In other cases the status of the intended observation is “aborted” and the result will never come.PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
 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 … 1MDate and time the observation has been madePaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
hl7:value
ANY0 … *RObservation values using the appropriate data type.

Numeric results use data type PQ, which includes the unit. The result is absent in case of ‘aborted’ observation.
PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
 ConstraintThe default data type, cardinalities and value set for the <value> element are dependant on the type of observation.
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.11 AP Observation (2015‑11‑22 12:20:34)
 Example
for observation on tumor type
<value code="8500/3" codeSystem="2.16.840.1.113883.6.43.1" codeSystemName="ICD-O-3" displayName="Invasive carcinoma of the breast, no special type"/>
hl7:interpretationCode
CE (extensible)0 … 1R

One or more codes interpreting the result, expressed with ObservationInterpretation vocabulary (e.g., H = high, L = low). 

    This element may be coded with other values than those of the ObservationInterpretation vocabulary, given that the coding strength is CWE (coded with exceptions).

PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26)
hl7:methodCode
CE (extensible)0 … 1RPaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (2014‑03‑26)
hl7:performer
II0 … 1CPerforming lab

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 TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
 ConstraintThe performing laboratory is present at this level only if this particular observation was performed by a (subcontractor) laboratory distinct from the one issuing the rest of the observations in this organizer.
hl7:author
II0 … *CAuthor

Source: PaLM TF 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 TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
hl7:informant
II0 … *RInformant

Source: PaLM TF 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 TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
hl7:participant
II0 … *RAdditional participants

Source: PaLM TF 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 TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
hl7:entryRelationship
0 … *RSub-Observation

The result obtained for an observation may lead to an additional AP observation to refine this result. This sub-observation is again an Anatomic Pathology Observation.

Source: Source: PaLM TF 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 TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *REmbedded image. 

This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest. 

Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.8



Contains 1.3.6.1.4.1.19376.1.8.1.4.10 Embedded Image (2016‑06‑22 16:08:01)		PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *RRegion of Interest







Contains 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (2005‑09‑07)		PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
@typeCode
cs1 … 1FCOMP
 ConstraintThis observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest.
In the latter case by an entryRelationship @typeCode="SUBJ"
hl7:entryRelationship
0 … *RAnnotation comment







Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20)		PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
@typeCode
cs0 … 1FCOMP
Included1 … *M from 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30)
Specimen identification
 Example
Example for specimen referencing
<specimen>
  <!-- which specimen is used for this observation -->
  <specimenRole>
    <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="slide_A_1_PR"/>  </specimenRole></specimen>
hl7:specimen
1 … *MRequired 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:reference
0 … *RReference to an external document, 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 TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation