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Template Anatomic Pathology Structured Report Content Module 2014‑05‑13 11:57:57

Id1.3.6.1.4.1.19376.1.8.1.1.1Effective Date2014‑05‑13 11:57:57
Statusdraft DraftVersion Label2.0
NameAnatomicPathologyStructuredReportContentModuleDisplay NameAnatomic Pathology Structured Report Content Module
Description
Anatomic Pathology Structured Report Content Module.
This document content module represents the generic set of constraints applied to any structured report for surgical pathology in all fields of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as for Cytopathology.
The body of this Document Content Module specifies a common hierarchy of sections and entries depicted by figure 10.4.1-1 in Volume 1 IHE_PaLM_Suppl_APSR 2.0. The only mandatory section is the Diagnostic Conclusion Section. And the only mandatory entry is the Problem Organizer Entry below this section.
ContextPathname /
LabelPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 14 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-76draft Secretary draft APSR 2.0
psr-dataelement-38draft Custodian draft APSR 2.0
psr-dataelement-78draft Clinician draft APSR 2.0
psr-dataelement-48draft Ordering Provider draft APSR 2.0
psr-dataelement-52draft Specimen Collector draft APSR 2.0
psr-dataelement-82draft Placer group ID draft APSR 2.0
psr-dataelement-49draft Order ID draft APSR 2.0
psr-dataelement-58draft Anatomic Pathology Structured Report draft APSR 2.0
psr-dataelement-81draft Order placer ID draft APSR 2.0
psr-dataelement-50draft Accession Number draft APSR 2.0
Used by / Uses
Used by 1 transaction and 0 templates, Uses 20 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
Uses as NameVersion
1.3.6.1.4.1.19376.1.3.3.1.1Includeactive Human Patient (2017)2017‑06‑07
1.3.6.1.4.1.19376.1.3.3.1.4Includeactive XD-LAB Information Recipient (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.3.1.6Includeactive Ordering Provider (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.3.1.7Containmentactive Laboratory Performer (2017)2008‑08‑08
1.3.6.1.4.1.19376.1.3.10.2.4Includeactive XD-LAB LegalAuthenticator (2017)2016‑07‑05
1.3.6.1.4.1.19376.1.3.10.2.5Includedraft Participant Pertinent Insurance Information2017‑11‑13 16:52:30
1.3.6.1.4.1.19376.1.3.10.3.1Containmentdraft Additional Specified Observation Section (2.0)2016‑11‑13 14:28:08
1.3.6.1.4.1.19376.1.8.1.2.1Containmentdraft 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
1.3.6.1.4.1.19376.1.8.1.2.6Containmentdraft Procedure Steps Section (2.0)2014‑05‑13 19:33:12
1.3.6.1.4.1.19376.1.8.1.4.1Includedraft Specimen Collector in Header2016‑06‑13 14:21:13
1.3.6.1.4.1.19376.1.8.1.4.2Includedraft Author (2.0)2016‑06‑21 14:02:11
1.3.6.1.4.1.19376.1.8.1.4.3Includedraft Content Validator2016‑07‑09 15:03:59
1.3.6.1.4.1.19376.1.8.1.4.6Containmentdraft Informant (2.0)2016‑07‑08 11:22:58
2.16.840.1.113883.10.12.103Includeactive CDA dataEnterer2005‑09‑07
2.16.840.1.113883.10.12.104Includeactive CDA custodian2005‑09‑07
2.16.840.1.113883.10.12.113Includeactive CDA componentOf2005‑09‑07
RelationshipSpecialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-
Example
example for use case #1
<ClinicalDocument xsi:schemaLocation="urn:hl7-org:v3 infrastructure/cda/CDA_extended.xsd">
  <realmCode code="UV"/>  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>  <templateId root="1.3.6.1.4.1.19376.1.8.1.1.1"/>  <!-- Identifier of this instance of the report -->
  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_1" assigningAuthorityName="IHE PaLM Technical Committee"/>  <!-- Type of document -->
  <code code="60568-3" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology Synoptic report"/>  <title>Anatomic Pathology Structured Report - Breast Biopsy</title>  <effectiveTime value="201001041605-0500"/>  <confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25"/>  <languageCode code="en-US"/>  <!-- common identifier to all releases of this report, extension is accession number -->
  <setId root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008" assigningAuthorityName="IHE PaLM Technical Committee"/>  <versionNumber value="1"/>  <!-- Patient -->
  <recordTarget>
    <patientRole>
      <id extension="0411886319605719371016" root="1.3.6.1.4.1.19376.1.8.9.2"/>      <addr use="HP">
        <streetAddressLine>39 East Street</streetAddressLine>        <postalCode>69499</postalCode>        <city>Appleton</city>        <state>WI</state>        <country>United States</country>      </addr>
      <telecom nullFlavor="NASK"/>      <patient>
        <name>
          <prefix>Miss</prefix>          <given>EVE</given>          <family qualifier="BR">ONEWOMAN</family>        </name>
        <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>        <birthTime value="19710921"/>      </patient>
    </patientRole>
  </recordTarget>
  <!-- one or more author(s) of the report, with authoring time -->
  <author>
    <templateId root="1.3.6.1.4.1.19376.1.8.1.4.2"/>    <time value="20100104131933-0500"/>    <assignedAuthor>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>      <addr nullFlavor="MSK"/>      <telecom value="tel:+33-602030499"/>      <assignedPerson>
        <name>
          <given>Marcel</given>          <family>Pathologist</family>          <suffix>Ph D</suffix>        </name>
      </assignedPerson>
      <representedOrganization>
        <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>        <name>CANCER INSTITUTE</name>        <telecom nullFlavor="MSK"/>        <addr nullFlavor="MSK"/>      </representedOrganization>
    </assignedAuthor>
  </author>
  <!-- one or more transcriptionists, with transcription time -->
  <dataEnterer>
    <time value="20100104131720-0500"/>    <assignedEntity>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="A32"/>      <addr nullFlavor="MSK"/>      <telecom nullFlavor="MSK"/>      <assignedPerson>
        <name>
          <given>Adeline</given>          <family>Medsecret</family>        </name>
      </assignedPerson>
    </assignedEntity>
  </dataEnterer>
  <informant>
    <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Body) APSR2', not used in use case #1 -->
  </informant>
  <!-- The unique custodian of this document is the sending pathology lab that will administer it (further updates, deprecation) -->
  <custodian>
    <assignedCustodian>
      <representedCustodianOrganization>
        <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>        <name>CANCER INSTITUTE</name>        <telecom use="PUB" value="0466666666"/>        <addr>
          <streetAddressLine>38 Cramberry Street</streetAddressLine>          <postalCode>69499</postalCode>          <city>Appleton</city>          <state>WI</state>        </addr>
      </representedCustodianOrganization>
    </assignedCustodian>
  </custodian>
  <!-- One or more additional intended recipients (other than the ordering physician) -->
  <informationRecipient>
    <templateId root="1.3.6.1.4.1.19376.1.3.3.1.4"/>    <intendedRecipient>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="987"/>      <addr>
        <streetAddressLine>1600 Clifton Road</streetAddressLine>        <city>Atlanta</city>        <state>GA</state>        <postalCode>30333</postalCode>      </addr>
      <telecom value="tel:404-639-3535"/>      <informationRecipient>
        <name>
          <family>WOULDLIKETOKNOW</family>          <given>Thomas</given>        </name>
      </informationRecipient>
    </intendedRecipient>
  </informationRecipient>
  <!-- The unique legal authenticator: The person assuming the final responsibility of the report and signing it -->
  <legalAuthenticator>
    <time value="20100104152503-0500"/>    <signatureCode code="S"/>    <assignedEntity>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>      <assignedPerson>
        <name>
          <given>Marcel</given>          <family>Pathologist</family>        </name>
      </assignedPerson>
    </assignedEntity>
  </legalAuthenticator>
  <!-- Zero or more additional content validator(s): pathologists having validated some part of the report -->
  <authenticator>
    <templateId root="1.3.6.1.4.1.19376.1.8.1.4.3"/>    <time value="20100104142503-0500"/>    <signatureCode code="S"/>    <assignedEntity>
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567898"/>      <addr nullFlavor="MSK"/>      <telecom nullFlavor="MSK"/>      <assignedPerson>
        <name>
          <given>Jonas</given>          <family>Jones</family>          <prefix>MD</prefix>        </name>
      </assignedPerson>
    </assignedEntity>
  </authenticator>
  <!-- The ordering physician -->
  <participant typeCode="REF">
    <templateId root="1.3.6.1.4.1.19376.1.3.3.1.6"/>    <time>
      <high value="20091231"/>    </time>
    <associatedEntity classCode="PROV">
      <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567892"/>      <addr nullFlavor="NASK"/>      <telecom value="tel:0147150000" use="EC"/>      <associatedPerson>
        <name>
          <prefix>Doctor</prefix>          <given>Eva</given>          <family>Surgeon</family>          <suffix>Ph D</suffix>        </name>
      </associatedPerson>
    </associatedEntity>
  </participant>
  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.1 'CDA participant specimen collector' 0..* R, not used in use case #1 -->
  <!-- include template 1.3.6.1.4.1.19376.1.3.10.2.5 'CDA participant pertinent insurance information' 0..1 R, not used in use case #1 -->
  <!-- Identification of the order, extension is Order-ID -->
  <inFulfillmentOf>
    <order>
      <id root="1.3.6.1.4.1.19376.1.8.9.8" extension="12345"/>    </order>
  </inFulfillmentOf>
  <!-- Documented act(s): The pathology examination procedure, extension is Accession number -->
  <documentationOf>
    <serviceEvent>
      <id root="1.3.6.1.4.1.19376.1.8.9.9" extension="A7102400008"/>      <code code="371528001" displayName="Pathology report (record artifact)" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>      <!-- Status of the report -->
      <lab:statusCode code="completed"/>      <effectiveTime>
        <!-- Start: Date&time of reception of this order and the attached specimens -->
        <low value="200912300922-0500"/>        <!-- End -->
        <high value="201001041605-0500"/>      </effectiveTime>
      <!-- Performing laboratory -->
      <performer typeCode="PRF">
        <templateId root="1.3.6.1.4.1.19376.1.3.3.1.7"/>        <time>
          <high value="201001041605-0500"/>        </time>
        <assignedEntity>
          <id root="1.3.6.1.4.1.19376.1.8.9.3" extension="801234567897"/>          <representedOrganization>
            <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="1120456789"/>            <name>CANCER INSTITUTE</name>            <telecom nullFlavor="MSK"/>            <addr nullFlavor="MSK"/>          </representedOrganization>
        </assignedEntity>
      </performer>
    </serviceEvent>
  </documentationOf>
  <!-- include template 1.3.6.1.4.1.19376.1.3.1.9999.10.9.16 'RelatedDocument Parent Document' 0..1 R, not used in use case #1 -->
  <!-- Patient encounter: The patient stay in the hospital where the surgery was performed -->
  <componentOf>
    <encompassingEncounter>
      <id root="1.3.6.1.4.1.19376.1.8.9.7" extension="234567890"/>      <code code="ACUTE" displayName="inpatient acute"/>      <effectiveTime>
        <high value="2201001040735-0500"/>      </effectiveTime>
      <location typeCode="LOC">
        <healthCareFacility classCode="SDLOC">
          <id root="1.3.6.1.4.1.19376.1.8.9.4" extension="11223344"/>          <serviceProviderOrganization classCode="ORG" determinerCode="INSTANCE">
            <name>Surgery theater</name>            <asOrganizationPartOf>
              <wholeOrganization>
                <name>CANCER INSTITUTE</name>              </wholeOrganization>
            </asOrganizationPartOf>
          </serviceProviderOrganization>
        </healthCareFacility>
      </location>
    </encompassingEncounter>
  </componentOf>
  <!-- Structured body -->
  <component typeCode="COMP" contextConductionInd="true">
    <structuredBody classCode="DOCBODY" moodCode="EVN">
      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.1 'Clinical Information Section' (2014-05-13T14:38:08) -->
      </component>
      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.2 'Intraoperative Observation Section' (2014-05-13T19:29:16) -->
      </component>
      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.3 'Macroscopic Observation Section' (2014-05-13T11:57:09) -->
      </component>
      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.4 'Microscopic Observation Section' (2014-05-13T14:25:17) -->
      </component>
      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.3.10.3.1 'Additionally Specified Observation Section' (2016-11-13T14:28:08) -->
      </component>
      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.5 'Diagnostic Conclusion Section' (2014-05-13T19:31:26) -->
      </component>
      <component typeCode="COMP" contextConductionInd="true">
        <!-- template 1.3.6.1.4.1.19376.1.8.1.2.6 'Procedure Steps Section' (2014-05-13T19:33:12) -->
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
 
target
psr-dataelement-58draft Anatomic Pathology Structured Report draft APSR 2.0
@classCode
cs1 … 1FDOCCLIN
@moodCode
cs1 … 1FEVN
hl7:templateId
II1 … 1MThis element is identifying the set of constraints applied to the CDA R2 standard by this IHE specification of a AP report. The following templateId SHALL be present and valued as follows to indicate compliance with the APSR 2.0 content module specification.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
@root
uid1 … 1F1.3.6.1.4.1.19376.1.8.1.1.1
hl7:realmCode
CS (extensible)1 … 1MThis element SHALL be present and is valued from the RealmOfUse [2.16.840.1.113883.1.11.11050] subset, within the VocabularyDomainQualifier value set. In the international context of this profile used as it is without any further extension, the realm code SHALL be <realmCode code="UV"/> (universal).

Whenever a national extension has been defined and is used, the realm code SHALL identify this national extension.

PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
hl7:typeId
II1 … 1MThis element is a technology-neutral explicit reference to the standard CDA R2. It SHALL be present and valued as follows:
ClinicalDocument/typeId@root = "2.16.840.1.113883.1.3" (which is the OID for HL7 Registered models);
ClinicalDocument.typeId@extension = "POCD_HD000040" (which is the unique identifier for the CDA, Release Two Hierarchical Description).
PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
@root
uid1 … 1F2.16.840.1.113883.1.3
@extension
st1 … 1FPOCD_HD000040
hl7:id
II1 … 1MClinicalDocument/Id SHALL be present. It represents the unique instance identifier of the clinical document. The combination of the root and extension attributes SHALL provide a globally unique identifier, in accordance with CDA R2, without further constraints.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
@root
uid1 … 1RHere the OID for PAT exemplary instances, in practice the OID of the AP-LIS
@extension
st1 … 1RHere a hypothetical document ID, most often derived from the accession number
 ConstraintA report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report.
The unique id of the current revision of the report is carried by the id element, and is composed of 
  • id@root, which SHALL be an OID,
  • and optionally id@extension, which can be any string so that the concatenation of the two attributes root and extension provide a globally unique id, which identifies this release of the report. 
 Example
Report ID from use case #1
<id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_1" assigningAuthorityName="IHE PaLM Technical Committee"/>
hl7:code
CE (required)1 … 1MClinicalDocument/code SHALL be present. The document type of this content module is always
<code code="60568-3"
codeSystem="2.16.840.1.113883.6.1"
displayName="Pathology Synoptic report"
codeSystemName="LOINC"/>
PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
@code
CONF1 … 1F60568-3
@codeSystem
1 … 1F2.16.840.1.113883.6.1
@codeSystemName
1 … 1FLOINC
@displayName
1 … 1FPathology Synoptic report
hl7:title
ST1 … 1MThe APSR <title> SHALL be present. It is the local translation of the code@displayName.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
 Example
Report title from use case #1
<title>ANATOMIC PATHOLOGY REPORT - BREAST BIOPSY</title>
hl7:effectiveTime
TS1 … 1MClinicalDocument/effectiveTime SHALL be present. It contains the creation date & time of the laboratory report as an electronic document. In case this is a new revision replacing a previous version (identified in parentDocument), this is the date & time of the new revision.
PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
hl7:confidentialityCode
CE (required)1 … 1MClinicalDocument/confidentialityCode SHALL be present in accordance with the HL7 CDA R2 standard.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (2014‑06‑09)
hl7:languageCode
CS (required)1 … 1MClinicalDocument/languageCode SHALL be present in accordance with the HL7 CDA R2 standard.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (2014‑03‑26)
hl7:setId
II1 … 1MClinicalDocument/setId SHALL be present to enable further updates of the clinical document. It is an identifier that is common across all revisions of this AP report.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
 
target
psr-dataelement-50draft Accession Number draft APSR 2.0
@root
uid1 … 1R
@extension
st1 … 1R
 ConstraintA report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report.
The setId element provides a globally unique identifier that is common across all successive revisions of the report. This identifier is similarly composed of setId@root, which SHALL be an OID, and optionally setId@extension.
 Example
Report set ID from use case #1
<id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008" assigningAuthorityName="IHE PaLM Technical Committee"/>
hl7:versionNumber
INT0 … 1RClinicalDocument/versionNumber MAY be present. As requested by the CDA standard, it is an integer value used as versioning.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
@value
int1 … 1R
 ConstraintA report may have several successive revisions over time, in case corrections or complements are provided by the custodian after the initial release of the report.
The version number of the current revision of the report is a positive integer (1, 2 …) provided in the versionNumber element.
 Example
Report version number for use case #1
<versionNumber value="1"/>
Included1 … 1M from 1.3.6.1.4.1.19376.1.3.3.1.1 Human Patient (2017‑06‑07)
The Patient.

The anatomic pathology report is related to ONE SINGLE patient.
  • A patient SHALL be identified with at least one unique patientRole/Id.
  • The patient address and telecom SHALL be provided (or null flavored).
  • The patient identity SHALL provide AT LEASTthe patient full name, sex and date/time of birth.
    hl7:recordTarget
    1 … 1MHumadotsrget
    hl7:patientRole
    1 … 1RHumadotsrget
    hl7:id
    II1 … *RHumadotsrget
    hl7:addr
    AD1 … *All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.Humadotsrget
    hl7:telecom
    TEL1 … *All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.Humadotsrget
    hl7:patient
    1 … 1Humadotsrget
    hl7:id
    II0 … 1Humadotsrget
    hl7:name
    PN1 … *Humadotsrget
    hl7:administrativeGenderCode
    CE1 … 1RHumadotsrget
    hl7:birthTime
    TS1 … 1RHumadotsrget
    Included1 … *M from 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11)
    The Author Content Module represents an author of the report. This element is repeatable. The sub-element  author/time  carries the date/time of the authoring action.

    At least one ClinicalDocument/author SHALL be present with a time in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. The author/time element carries the date&time the AP report was produced. The AP report can be authored by a software system or by a person or by both.

    Source: PaLM Suppl.APSR 2.0‑3: 6.3.6.2
    hl7:author
    1 … *MPaLM 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
    Included0 … *R from 2.16.840.1.113883.10.12.103 CDA dataEnterer (2005‑09‑07)
    Transcriptionist
    hl7:dataEnterer
    0 … *RCDAddotserer
    @typeCode
    cs0 … 1FENT
    @contextControlCode
    cs0 … 1FOP
    hl7:time
    TS0 … 1CDAddotserer
    hl7:assignedEntity
    1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAddotserer
     
    target
    psr-dataelement-76draft Secretary draft APSR 2.0
    hl7:informant
    0 … *RZero or more informant MAY be mentioned in the header of the report. An informant is either an  assignedEntity  (a professional participating to the healthcare process, and who was assigned a defined role in that process) or a  relatedEntity  (a person who knows the patient and has provided relevant information concerning the patient). Hence the condition is either  assignedEntity  is present or  relatedEntity  is present. In an anatomic pathology structured report informants are only healthcare professionals. There is no point for such a report to mention persons related to the patient (next of kin, employer, guarantor, …).

    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. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Included1 … 1M from 2.16.840.1.113883.10.12.104 CDA custodian (2005‑09‑07)
    ClinicalDocument/custodian SHALL be present with an id in accordance with the HL7 CDA R2 standard and further constrained by this specification to require the presence of name, addr and telecom. It represents the organization that is in charge of maintaining the AP report.
    hl7:custodian
    1 … 1MCDAcdotsdian
     
    target
    psr-dataelement-38draft Custodian draft APSR 2.0
    @typeCode
    cs0 … 1FCST
    hl7:assignedCustodian
    1 … 1CDAcdotsdian
    @classCode
    cs0 … 1FASSIGNED
    hl7:representedCustodianOrganization
    1 … 1CDAcdotsdian
    @classCode
    cs0 … 1FORG
    @determinerCode
    cs0 … 1FINSTANCE
    hl7:id
    II1 … *MCDAcdotsdian
    hl7:name
    ON0 … 1CDAcdotsdian
    hl7:telecom
    TEL0 … 1CDAcdotsdian
    hl7:addr
    AD0 … 1CDAcdotsdian
    Included0 … *R from 1.3.6.1.4.1.19376.1.3.3.1.4 XD-LAB Information Recipient (2008‑08‑08)
    The Intended Recipient Content Module represents a healthcare provider,  other than the ordering physician, expecting to receive a copy of the report. This repeatable element informationRecipient of the CDA header is used to list the intended recipients who were known at the time the report was created and issued. 

    Source: PaLM TF-3: 6.3.2.14
    hl7:informationRecipient
    0 … *RInfodotsient
    hl7:templateId
    II1 … 1MInfodotsient
    @root
    uid1 … 1F1.3.6.1.4.1.19376.1.3.3.1.4
    hl7:intendedRecipient
    1 … 1RInfodotsient
    hl7:id
    II0 … *RInfodotsient
    hl7:addr
    AD1 … *Infodotsient
    hl7:telecom
    TEL1 … *Infodotsient
    hl7:informationRecipient
    0 … 1Contains 1.3.6.1.4.1.19376.1.3.10.9.18 PlayingEntity or person with Name (DYNAMIC)Infodotsient
    hl7:receivedOrganization
    0 … 1Contains 1.3.6.1.4.1.19376.1.3.10.9.13 Organization with Name, Addr, Telecom (DYNAMIC)Infodotsient
    Included1 … 1M from 1.3.6.1.4.1.19376.1.3.10.2.4 XD-LAB LegalAuthenticator (2016‑07‑05)
    The Legal authenticator Content Module describes a pathologist having verified the content of the report, using the element legalAuthenticator.

    The report SHALL have one legal Authenticator.

    Source: PaLM TF-3: 6.3.2.15

    hl7:legalAuthenticator
    1 … 1MIHEHdotsator
    hl7:time
    TS1 … 1R

    The sub-element time carries the date&time this legal authentication took place.

    IHEHdotsator
    hl7:signatureCode
    CS1 … 1R

    The sub-element signatureCode carries the “signed” (S) status

    IHEHdotsator
    @code
    CONF0 … 1FS
    hl7:assignedEntity
    1 … 1R

    All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.

    IHEHdotsator
    hl7:addr
    AD1 … *R

    Constrained by this specification to require the presence of name, addr and telecom.

    IHEHdotsator
    hl7:telecom
    TEL1 … *R

    Constrained by this specification to require the presence of name, addr and telecom.

    IHEHdotsator
    hl7:assignedPerson
    0 … 1

    All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.


    Contains 1.3.6.1.4.1.19376.1.3.10.9.18 PlayingEntity or person with Name (DYNAMIC)
    IHEHdotsator
    hl7:representedOrganization
    0 … 1

    All persons (including the patient) and organizations mentioned in the document SHALL provide elements name, addr and telecom.


    Contains 1.3.6.1.4.1.19376.1.3.10.9.13 Organization with Name, Addr, Telecom (DYNAMIC)
    IHEHdotsator
    Included0 … *R from 1.3.6.1.4.1.19376.1.8.1.4.3 Content Validator (2016‑07‑09 15:03:59)
    The Content validator Content Module describes a pathologist having verified the content of the report, using the element authenticator. This element authenticator is used when the pathologist having verified the content of the report is distinct from the pathologist assuming the legal responsibility for this report, described in the legalAuthenticator element.

    The report MAY have zero or more Content Validators.

    Source: PaLM Suppl. APSR 2.0-3: 6.3.6.3 

    hl7:authenticator
    0 … *RPaLM Suppl. APSR 2.1‑3: 6.3.2.2 Content validator
     
    target
    psr-dataelement-4draft Pathologist draft APSR 2.0
    @typeCode
    cs1 … 1FAUTHEN
    hl7:templateId
    1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.2.2 Content validator
    @root
    uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.3
    hl7:time
    TS1 … 1RTime of validationPaLM Suppl. APSR 2.1‑3: 6.3.2.2 Content validator
    hl7:assignedEntity
    0 … 1CAssignedPerson SHALL be given with name, representedOrganization MAY be given.
    Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (2005‑09‑07)
    PaLM Suppl. APSR 2.1‑3: 6.3.2.2 Content validator
    Included1 … 1R from 1.3.6.1.4.1.19376.1.3.3.1.6 Ordering Provider (2008‑08‑08)
    The Ordering Provider Content Module represents the physician who has submitted the specimen examination order to the anatomic pathology laboratory. As specified in PaLM TF-3, this physician is represented in the CDA header as a participant element with the typeCode attribute valued “REF”. The sub-element participant/time carries the date/time of issuance of the order.

    Source:  PaLM TF-3: 6.3.2.17
    hl7:participant
    1 … 1RReferral Ordering PhysicianOrdedotsider
     
    target
    psr-dataelement-78draft Clinician draft APSR 2.0
    psr-dataelement-48draft Ordering Provider draft APSR 2.0
    @typeCode
    cs1 … 1FREF
    hl7:templateId
    II1 … 1Ordedotsider
    @root
    uid1 … 1F1.3.6.1.4.1.19376.1.3.3.1.6
    hl7:time
    IVL_TS1 … 1RThis element represents the date and time the order was placed. Time MAY be present.Ordedotsider
    hl7:associatedEntity
    1 … 1Ordedotsider
    hl7:addr
    AD1 … *RThe address of this person (referral ordering physician) SHALL be present.Ordedotsider
    hl7:telecom
    TEL1 … *RThe telecom of this person (referral ordering physician) SHALL be present.Ordedotsider
     Schematron assertrolered error 
     testnot(hl7:assignedPerson) or hl7:assignedPerson/hl7:name 
     MessageThe <name> sub-element SHALL be present when <assignedPerson> present. 
    hl7:associatedPerson
    0 … 1ROrdedotsider
    hl7:scopingOrganization
    0 … 1Ordedotsider
    Included0 … *R from 1.3.6.1.4.1.19376.1.8.1.4.1 Specimen Collector in Header (2016‑06‑13 14:21:13)
    Specimen Collector other than ordering physician. 

    Source: PAT TF-3: 6.2.6.1

    hl7:participant
    0 … *RThe Specimen Collector Content Module is only used in case a specimen provided as input to the AP act documented in this report, was collected by a different party than the ordering physician. In that case, this specimen collector is represented in the CDA header as a participant element with the typeCode attribute valued “DIST” and the sub-element participant/time carries the time period of the specimen collection.PaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
     
    target
    psr-dataelement-78draft Clinician draft APSR 2.0
    psr-dataelement-52draft Specimen Collector draft APSR 2.0
    @typeCode
    cs1 … 1FDIST
    hl7:templateID
    II1 … 1MPaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    @root
    uid1 … 1F1.3.6.1.4.1.19376.1.8.1.4.1
    hl7:time
    IVL_TS1 … 1MSpecimen collection time

    The specimen collection time is an interval, which may be reduced to a point in time (see usage of data type IVL_TS).

    PaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    hl7:associatedEntity
    0 … 1RAt least one of the two elements associatedPerson and scopingOrganization must be present. Both may be present. 

    PaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    @classCode
    cs1 … 1FPROV
    hl7:id
    II1 … *RPaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    hl7:addr
    AD1 … *RPaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    hl7:telecom
    TEL1 … *RPaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    hl7:associatedPerson
    0 … *CPerson who collected the specimen.
    Only full name(s) SHALL be given.
    Contains 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
    PaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    hl7:scopingOrganization
    0 … 1COrganization taking care for specimen collection.
    Identifiers, name, telecom, and address SHOULD be given.
    Contains 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)
    PaLM Suppl. APSR 2.1‑3:6.3.2.1 Specimen collector
    Included0 … 1R from 1.3.6.1.4.1.19376.1.3.10.2.5 Participant Pertinent Insurance Information (2017‑11‑13 16:52:30)
    Key insurance information of the patient.
    hl7:participant
    0 … 1RInsurance information of the patient in context for reporting to cancer registries (in Germany)PaLM Suppl. 2.1‑3:6.3.2.3
    @typeCode
    cs1 … 1FHLD
    hl7:templateId
    II1 … *MPaLM Suppl. 2.1‑3:6.3.2.3
    @root
    uid1 … 1F1.3.6.1.4.1.19376.1.3.10.2.5
    hl7:time
    IVL_TS0 … 1Rtime shows the end of the current insurance period, e.g. end of the quartalPaLM Suppl. 2.1‑3:6.3.2.3
     Example<time>
      <high value="20171231"/></time>
    hl7:associatedEntity
    1 … 1MData of the insured personPaLM Suppl. 2.1‑3:6.3.2.3
    @classCode
    cs1 … 1FPOLHOLD
    hl7:id
    II0 … *RID(s) of the insured person (patient), e.g. ID of the insured, ID of the health card, etc.PaLM Suppl. 2.1‑3:6.3.2.3
    hl7:code
    CE0 … 1Rstatus of the insured personPaLM Suppl. 2.1‑3:6.3.2.3
    @codeSystem
    CONF0 … 1F2.16.840.1.113883.5.111
     Example<code code="SELF" codeSystem="2.16.840.1.113883.5.111" displayName="self">
      <translation code="1" codeSystem="2.16.840.1.113883.3.7.1.1" displayName="member"/></code>
    hl7:translation
    CV0 … 1Rfurther codes of the status of the insured person,

    e.g. for Germany from value set S_KBV_VERSICHERTENSTATUS 1.2.276.0.76.11.162
    PaLM Suppl. 2.1‑3:6.3.2.3
    hl7:addr
    AD0 … 1RPaLM Suppl. 2.1‑3:6.3.2.3
    hl7:telecom
    TEL0 … *RPaLM Suppl. 2.1‑3:6.3.2.3
    hl7:associatedPerson
    0 … 1RData of the insured person, which may be different from the patient. 
    Contains 2.16.840.1.113883.10.12.152 CDA Person (2005‑09‑07)
    PaLM Suppl. 2.1‑3:6.3.2.3
    hl7:scopingOrganization
    1 … 1RData of the Insurance company, including the ID, the address data and the name.
    In Germany the ID is formed by the ID itself (@extension = so-called IKNR) and the OID for IKNR  (@root="1.2.276.0.76.4.5") in Germany.
    Contains 2.16.840.1.113883.10.12.151 CDA Organization (2005‑09‑07)
    PaLM Suppl. 2.1‑3:6.3.2.3
    hl7:inFulfillmentOf
    0 … 1RThe inFulfillmentOf/order element MAY be present. It represents the Placer Order or the Placer Group that was fulfilled, the Id of which is carried by inFulfillmentOf/order/id.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
     
    target
    psr-dataelement-49draft Order ID draft APSR 2.0
    @typeCode
    cs1 … 1FFLFS
    hl7:order
    1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    @classCode
    cs1 … 1FACT
    @moodCode
    cs1 … 1FRQO
    hl7:id
    II1 … *RPlacer order group ID or Placer order ID.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
     
    target
    psr-dataelement-82draft Placer group ID draft APSR 2.0
    psr-dataelement-81draft Order placer ID draft APSR 2.0
    hl7:documentationOf
    1 … 1MDocumented act.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    @typeCode
    cs1 … 1FDOC
    hl7:serviceEvent
    1 … 1MThe AP report is documenting a service (documentationOf/serviceEvent) performed by a surgical pathology laboratory. The Laboratory Performer Content Module represents this laboratory, and is fully described in the sub-element documentationOf/serviceEvent/performer.
    In case more than one laboratory contributed to a service, only the primary laboratory is in the CDA header, attached to the serviceEvent element, and the other (secondary) laboratories are described only in the sections of the report that they contributed to, in the body of the report.


    Source: PaLM TF3: 6.3.2.19

    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    @classCode
    cs1 … 1R
    @moodCode
    cs1 … 1R
    hl7:id
    II1 … *MID of the Act, i.e. Accession numberPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
     
    target
    psr-dataelement-82draft Placer group ID draft APSR 2.0
    psr-dataelement-49draft Order ID draft APSR 2.0
    hl7:code
    CE (extensible)0 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
     CONF
    @code shall be "PATREPE"
    @codeSystem shall be "2.16.840.1.113883.5.4"
    @codeSystemName shall be "HL7 ActCode"
    @displayName shall be "pathology report entry task"
    or
    @code shall be "371528001"
    @codeSystem shall be "2.16.840.1.113883.6.96"
    @codeSystemName shall be "SCT"
    @displayName shall be "Pathology report (record artifact)"
    hl7:effectiveTime
    IVL_TS0 … 1RUse of sub element documentationOf/serviceEvent/effectiveTime to document the time boundaries of events in the document is appropriate.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    lab:statusCode
    CS (required)0 … 1RThe statusCode below documentationOf/serviceEvent is an extension to the CDA R2 standard, added by PaLM TF-3 to distinguish a preliminary report (statusCode@code="active") from a final report (statusCode@code="completed"). 
    The statusCode sub element is  further described in section A.3 of PaLM TF-3. This sub-element is required. When it is not there, the documented Act is assumed to be completed and the report is assumed to be a final report.
    This extension to the standard is protected by a dedicated namespace associated in the ClinicalDocument element to the prefix lab:

    <Clinical Document  xmlns:lab="urn:oid:1.3.6.1.4.1.19376.1.3.2" … > 

    Source: PaLM TF3: 6.3.2.19
    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
     ConstraintThe statusCode@code="completed" is only applicable, if ALL content modules of the Clinical Document have the statusCode@code="completed", too, or have the statusCode@code="aborted".
     CONF
    The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.3.11.4 ActStatusActiveCompleted (2008‑08‑08)
     Schematron assertrolered error 
     testhl7:serviceEvent/lab:statusCode[@code='completed'] 
     MessageStatus code of all Content Modules SHALL be "complete" or "aborted" 
    hl7:performer
    0 … *RContains 1.3.6.1.4.1.19376.1.3.3.1.7 Laboratory Performer (2008‑08‑08)PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    hl7:relatedDocument
    0 … 1R

    ClinicalDocument/relatedDocument/parentDocument

    This element SHALL be present in case of an update replacement of a previous report. In this case relatedDocument@typeCode attribute SHALL be valued "RPLC", the new report replacing the parent one.

    Note 1: A non-final AP structured report published in an XDS infrastructure will likely be replaced afterwards by the final report. When this event occurs, the Content Creator Actor SHALL apply the following rules:

    • ClinicalDocument/setId SHALL have the same value in the new report as in the replaced report.
    • ClinicalDocument/versionNumber SHALL be incremented in the replacing report (i.e., the final one).
    • ClinicalDocument/relatedDocument@typeCode attribute SHALL be valued ”RPLC”
    • ClinicalDocument/relatedDocument/parentDocument/id in the new report SHALL be equal to ClinicalDocument/ id of the replaced document.

    The Document Source Actor SHALL apply the following rules on XDSDocumentEntry metadata:

    • The final report SHALL be associated with the previously published one, using RPLC relationship and the previous report SHALL be “Deprecated” as described in ITI TF-2:4.1.6.1.

    Note 2: A non-final report can also be replaced by a more recent, albeit still non-final report. The rules above also apply in this case.

    Note 3: A final report can also be replaced by a corrective final report. The rules above also apply in this case.

    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    @typeCode
    cs1 … 1FRPLC
     relatedDocument@typeCode attribute SHALL be valued "RPLC"
    hl7:parentDocument
    ANY1 … 1MPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    hl7:id
    II1 … 1MSHALL be equal to ClinicalDocument/ id of the replaced document.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    hl7:setId
    II1 … 1MSHALL have the same value in the new report as in the replaced report.PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    hl7:versionNumber
    INT0 … 1RSHALL have the same value as in the replaced report (when provided there).PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    Included0 … 1R from 2.16.840.1.113883.10.12.113 CDA componentOf (2005‑09‑07)
    The ClinicalDocument/componentOf/encompassingEncounter element MAY be present.

    It describes the encounter during which the reported AP observations were ordered. When present the encounter SHALL:

    • be identified with an id element: encompassingEncounter/id
    • The encounter SHALL have an effective time that represents the time interval (possibly still running, e.g., an inpatient current stay) of the encounter or a point in time at which the encounter took place (e.g., an outpatient consultation): encompassingEncounter/ effectiveTime

    The encounter MAY provide any number of encounter participants (encompassingEncounter/encounterParticipant/assignedEntity). When present, encounter participants SHALL be in accordance with the HL7 CDA R2 standard with a time and further constrained by this specification to require the presence of name, addr and telecom. Additionally, the encounter participant SHALL have a typeCode with one the values selected from the x_EncounterParticipant domain: The encounter MAY precise the patient location during this encounter. This is the healthcare facility in which the patient was located when the reported AP observations were ordered: encompassingEncounter/location/healthCareFacility. This healthcare facility can be represented as a physical place (e.g., room, floor, building, office) or as an organization (e.g., service, department, team) or both: healthCareFacility/location, healthCareFacility/serviceProviderOrganization.

    hl7:componentOf
    0 … 1RCDAcdotsntOf
    @typeCode
    cs0 … 1FCOMP
    hl7:encompassingEncounter
    1 … 1CDAcdotsntOf
    @classCode
    cs0 … 1FENC
    @moodCode
    cs0 … 1FEVN
    hl7:id
    II0 … *CDAcdotsntOf
    hl7:code
    CE0 … 1CDAcdotsntOf
     CONF
    The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.13955 ActEncounterCode (DYNAMIC)
    hl7:effectiveTime
    IVL_TS1 … 1RCDAcdotsntOf
    hl7:dischargeDispositionCode
    CE0 … 1CDAcdotsntOf
     CONF
    shall be drawn from concept domain "EncounterDischargeDisposition"
    hl7:responsibleParty
    0 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAcdotsntOf
    @typeCode
    cs0 … 1FRESP
    hl7:encounterParticipant
    0 … *CDAcdotsntOf
    @typeCode
    cs1 … 1R
     CONF
    The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19600 x_EncounterParticipant (DYNAMIC)
    hl7:time
    IVL_TS0 … 1CDAcdotsntOf
    hl7:assignedEntity
    1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)CDAcdotsntOf
    hl7:location
    0 … 1CDAcdotsntOf
    @typeCode
    cs0 … 1FLOC
    hl7:healthCareFacility
    1 … 1CDAcdotsntOf
    @classCode
    cs0 … 1FSDLOC
    hl7:id
    II0 … *CDAcdotsntOf
    hl7:code
    CE0 … 1CDAcdotsntOf
     CONF
    The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.17660 ServiceDeliveryLocationRoleType (DYNAMIC)
    hl7:location
    0 … 1Contains 2.16.840.1.113883.10.12.317 CDA Place (DYNAMIC)CDAcdotsntOf
    hl7:serviceProviderOrganization
    0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)CDAcdotsntOf
    hl7:component
    1 … 1RBody of the CDA Clinical documentPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    @typeCode
    cs1 … 1FCOMP
    @contextConductionInd
    bl1 … 1Ftrue
    hl7:structuredBody
    1 … 1RPaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    @classCode
    cs1 … 1FDOCBODY
    @moodCode
    cs1 … 1FEVN
    hl7:component
    0 … 1RThe Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, clinical laboratory data, specimen(s) description, collection procedure, reason for anatomic pathology procedure.
    Contains 1.3.6.1.4.1.19376.1.8.1.2.1 Clinical Information Section (2014‑05‑13 14:38:08)
    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    @typeCode
    cs1 … 1FCOMP
    @contextConductionInd
    bl1 … 1Ftrue
    hl7:component
    0 … 1RThe Intraoperative Observation section contains an intraoperative diagnosis for each specimen examined, the specimen identification and description, intraoperative observation procedure description (frozen section, gross examination, intraoperative cytology) and derived specimen dissected for other ancillary procedures (flow cytometry, cytogenetics, molecular studies, and electron microscopy). 
    Contains 1.3.6.1.4.1.19376.1.8.1.2.2 Intraoperative Observation Section (2014‑05‑13 19:29:16)
    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    @typeCode
    cs1 … 1FCOMP
    @contextConductionInd
    bl1 … 1Ftrue
    hl7:component
    0 … 1RThe Macroscopic Observation section contains the description of the specimen received or obtained by the laboratory (specimen type and state), the gross observation, links to gross images, if taken, processing information and tissue disposition (representative sampling and tissue submitted for additional studies or sent to biorepository.
    Contains 1.3.6.1.4.1.19376.1.8.1.2.3 Macroscopic Observation Section (2014‑05‑13 11:57:09)
    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    @typeCode
    cs1 … 1FCOMP
    @contextConductionInd
    bl1 … 1Ftrue
    hl7:component
    0 … 1RThe Microscopic Observation section contains optionally the histopathologic findings of the case and many laboratories use this section to record the results of histochemical and immunohistochemical stains
    Contains 1.3.6.1.4.1.19376.1.8.1.2.4 Microscopic Observation Section (2014‑05‑13 14:25:17)
    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    @typeCode
    cs1 … 1FCOMP
    @contextConductionInd
    bl1 … 1Ftrue
    hl7:component
    0 … 1RThe Additional Specific Observation section includes additional pathologic finding(s) and the results of ancillary study(ies) with non-morphological methods (e.g. flow cytometry, cytogenetics, molecular pathology, etc.) and may include diagrams and still images or virtual slides, if taken. 
    Contains 1.3.6.1.4.1.19376.1.3.10.3.1 Additional Specified Observation Section (2016‑11‑13 14:28:08)
    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    @typeCode
    cs1 … 1FCOMP
    @contextConductionInd
    bl1 … 1Ftrue
    hl7:component
    1 … 1MThe 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.
    Contains 1.3.6.1.4.1.19376.1.8.1.2.5 Diagnostic Conclusion Section (2014‑05‑13 19:31:26)
    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    @typeCode
    cs1 … 1FCOMP
    @contextConductionInd
    bl1 … 1Ftrue
    hl7:component
    0 … 1RThe 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.
    Contains 1.3.6.1.4.1.19376.1.8.1.2.6 Procedure Steps Section (2014‑05‑13 19:33:12)
    PaLM Suppl. APSR 2.1‑3: 6.3.1.1 APSR document content module
    @typeCode
    cs1 … 1FCOMP
    @contextConductionInd
    bl1 … 1Ftrue