Transaction CDA Document Anatomic Pathology Structured Report 2015 2.0
ID: 2.16.840.1.113883.2.6.60.6.4.2Version Label: Live VersionConcepts: 80 (Groups: 28 - Items: 52)
Transaction CDA Document Anatomic Pathology Structured Report 2015 2.0ID: 2.16.840.1.113883.2.6.60.6.4.2Version Label: Live VersionConcepts: 80 (Groups: 28 - Items: 52) |
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| Name | ID[‑] | Mandatory[‑] | Conf[‑] | Card[‑] | Max[‑] | Datatype CC[‑] | Datatype[‑] | Property[‑] | Example[‑] | Codes[‑] | Description[‑] | Context[‑] | Source[‑] | Rationale[‑] | Operationalizations[‑] | Comment[‑] | Mapping[‑] | Condition[‑] | Enable when[‑] | Status[‑] | Terminology[‑] | Value Set[‑] | Type[‑] | Parent concept[‑] | Inherit from[‑] |
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| Anatomic Pathology Structured Report | psr-dataelement-58 | + | M | 1 … 1 | 1 | 1 … 1 M |
Anatomic pathology structured reports document the findings on specimens removed from patients for diagnostic or therapeutic reasons. This information can be used for patient care, clinical research and epidemiology. Standardizing and computerizing anatomic pathology reports is necessary to improve the quality of reporting and to facilitate the exchange the exchange and reuse of the content of these reports. This content profile describes a digital anatomic pathology report shared in a human-readable format, which may include images, and which also contains findings and observations in a machine-readable format, to facilitate the integration of these into the database of a consumer system, and to enable the application of automated reasoning to this content. The scope of this IHE content profile covers all fields of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as cytopathology. |
IHE Pathology and Laboratory Medicine Technical Framework V7.0, Suppl.APSR 2.0 |
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Pathology Synoptic report (Logical Observation Identifier Names and Codes: 60568-3)
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Group | |||||||||||||
| Custodian | psr-dataelement-38 | - | R | 1 … 1 | 1 | 1 … 1 R | Organization or person who takes care for physicians and other medical professionals (concerned with fulfillment of orders for pathology studies) |
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Legal guardian (person) | (SNOMED Clinical Terms: 58626002)
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Group | Anatomic Pathology Structured Report | |||||||||||||
| Pathologist | psr-dataelement-4 | - | R | 1 … 1 | 1 | 1 … 1 R | Pathologist is that professional who makes parts of the specimen preparation, investigates the microscopic slides, establish a diagnosis, and writes and sign a report to the clinician. It is a role for a person. |
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Anatomic pathologist (occupation) (SNOMED Clinical Terms: 83273008)
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Group | Custodian | |||||||||||||
| Lab technician | psr-dataelement-77 | - | R | 0 … 1 | 1 | 0 … 1 R String | String | That professional who takes care for specimen processing and operating devices in the pathology laboratory |
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Medical technician (occupation) (SNOMED Clinical Terms: 307988006)
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Item | Custodian | ||||||||||||
| Secretary | psr-dataelement-76 | - | R | 0 … 1 | 1 | 0 … 1 R String | String | The Secretary is that person who types the entire report or parts of it according a dictate of the pathologist. He or she also checks the billing details and takes care for sending the reports to the clinicians. It is a role for a person. |
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Secretary typist (occupation) (SNOMED Clinical Terms: 159569006)
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Item | Custodian | ||||||||||||
| Patient | psr-dataelement-2 | - | R | 1 … 1 | 1 | 1 … 1 R | Patient is the person, from whom the specimen under investigation comes. It is the recordTarget. It is a role for a person |
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Patient (person) (SNOMED Clinical Terms: 116154003)
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Group | Anatomic Pathology Structured Report | |||||||||||||
| (administrative) Gender | psr-dataelement-27 | - | R | 0 … 1 | 1 | 0 … 1 R Code | Code |
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(administrative) Gender |
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Gender identity (Logical Observation Identifier Names and Codes: 76691-5)
Gender (observable entity) (SNOMED Clinical Terms: 263495000)
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Administrative Gender (HL7 V3) 2016-06-23T00:00:00 (dynamic / Example)
AdministrativeGender 2019-11-01T09:29:23 (dynamic / Extensible/CWE)
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Item | Patient | ||||||||||
| Address | psr-dataelement-18 | - | R | 0 … 1 | 1 | 0 … 1 R | (Postal) Address |
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Patient address (observable entity) (SNOMED Clinical Terms: 184097001)
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Group | Patient | |||||||||||||
| Country | psr-dataelement-22 | - | R | 0 … 1 | 1 | 0 … 1 R String | String | Country |
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Item | Address | ||||||||||||
| City | psr-dataelement-21 | - | R | 1 … 1 | 1 | 1 … 1 R String | String | City |
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Item | Address | ||||||||||||
| ZIP Code | psr-dataelement-20 | - | R | 0 … 1 | 1 | 0 … 1 R Code | Code | ZIP Code for postal address |
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Item | Address | ||||||||||||
| Street | psr-dataelement-19 | - | R | 0 … 1 | 1 | 0 … 1 R String | String | Street as part of the address |
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Item | Address | ||||||||||||
| Name | psr-dataelement-5 | - | R | 1 … 1 | 1 | 1 … 1 R | Name, built of several name parts |
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Name (observable entity) (SNOMED Clinical Terms: 703503000)
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Group | Patient | |||||||||||||
| Surname | psr-dataelement-10 | - | R | 1 … 1 | 1 | 1 … 1 R String | String | Surname, given name |
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Item | Name | ||||||||||||
| Family Name | psr-dataelement-9 | - | R | 1 … 1 | 1 | 1 … 1 R String | String | Family name (name) |
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Item | Name | ||||||||||||
| Title | psr-dataelement-14 | - | R | 0 … 1 | 1 | 0 … 1 R String | String | Academic title |
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Item | Name | ||||||||||||
| Case | psr-dataelement-32 | - | R | 1 … 1 | 1 | 1 … 1 R | The specimen(s) from a patient, obtained by one or more specimen collection procedures and sent by a clinician (ordering provider) to the pathology laboratory at one time with one ore more clinical information and diagnostic problems. The specimen(s) can be sent in one or more than one containers. | HL7 Specimen DAM |
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Case - situation (qualifier value) (SNOMED Clinical Terms: 398241000)
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Group | Anatomic Pathology Structured Report | ||||||||||||
| Accession Number (Case-ID) | psr-dataelement-50 | + | M | 1 … 1 | 1 | 1 … 1 M Identifier | Identifier | <id root="1.3.6.1.4.1.19376.1.8.9.9" extension="A7102400008"/> | This is the ID for the case, known also as "Accession number", i.e. all specimen sent at the same time from the ordering provider to the pathology lab. There this ID is issued by the Order filler, corresponding with the Order filler ID. If more than one specimen from the same patient is sent at once by the clinician under the Placer group ID, then this Placer group ID corresponds with the Accession number! |
HL7 Specimen DAMIHE PAT TF-1 1.12 |
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Accession number and class of case and sequence number override flag Cancer case (Logical Observation Identifier Names and Codes: 42071-1)
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Item | Case | ||||||||||
| Order (Requested procedure) | psr-dataelement-33 | - | R | 1 … 1 | 1 | 1 … 1 R |
A request to perform examination of a specimen or a set of specimens taken from a patient, i.e. to perform procedures. The Order is the focal object of the transactions between Order Filler and Order Placer or Order Result Tracker. An Order may be standalone or belong to an Order Group. The Order Filler translates the received Orders into Requested Procedure(s), automatically assigns Study Accession Numbers. |
IHE-PAT TF1, 1.12 and 2.2 |
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Pathology order (record artifact) (SNOMED Clinical Terms: 721966001)
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Group | Anatomic Pathology Structured Report | ||||||||||||
| Clinical Information | psr-dataelement-40 | - | R | 0 … 1 | 1 | 0 … 1 R | Clinical Information to a case. |
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Finding / observation / clinical history (navigational concept) (SNOMED Clinical Terms: 362976009)
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Group | Order | |||||||||||||
| Clinical Problem | psr-dataelement-43 | - | R | 0 … * | n | 0 … * R Text | Text | Dignität? | Clinical Problem for that a pathology investigation has been ordered |
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Problem list - Reported (Logical Observation Identifier Names and Codes: 11450-4)
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Item | Clinical Information | |||||||||||
| History of Present Illness | psr-dataelement-42 | - | R | 0 … * | n | 0 … * R Text | Text | Gewichtsverlust von 10 kg über 6 Monate | History of present illness / complaints |
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Personal history finding (finding) (SNOMED Clinical Terms: 307294006)
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Item | Clinical Information | |||||||||||
| Reason for Referral | psr-dataelement-41 | - | R | 0 … * | n | 0 … * R Text | Text | bitte um histologische Abklärung des tumorverdächtigen Befundes | Reason for Referral |
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Reason for referral (narrative) (Logical Observation Identifier Names and Codes: 42349-1)
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Item | Clinical Information | |||||||||||
| Order ID | psr-dataelement-49 | - | R | 1 … 1 | 1 | 1 … 1 R | Identification of the order, issued by the Ordering Physician (Order Placer). If more than one Order is placed at the same time, those multiple orders are grouped by the Order placer group ID. |
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Group | Order | |||||||||||||
| Ordering Provider | psr-dataelement-48 | + | M | 1 … 1 | 1 | 1 … 1 M Text | Text | Role for a physician or clinician who requests an examination (making an order) on a case sent to a pathology laboratory ("Einsender" in German). When he uses an order entry system, this is issuing the placer order or the placer order group. |
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Ordering practitioner name (Logical Observation Identifier Names and Codes: 18781-5)
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Item | Order | ||||||||||||
| Specimen Collector | psr-dataelement-52 | - | R | 0 … * | n | 0 … * R Text | Text | Role for a person who collects a specimen, only in the situation where the specimen was not collected by the ordering physician | IHE_PAT_Suppl_APSR_Rev2 0_TI_2013_10_02 |
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Item | Order | |||||||||||
| Specimen | psr-dataelement-1 | - | R | 1 … * | n | 1 … * R |
A substance, physical object or collection of objects that the laboratory considers a single discrete, uniquely identified unit that is the subject of one or more steps in the laboratory workflow. This is usually a part, a block or a slide. |
HL/ DAM: Specimen, rel.1, May 2014 |
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Specimen (specimen) (SNOMED Clinical Terms: 123038009)
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Group | Anatomic Pathology Structured Report | ||||||||||||
| Part | psr-dataelement-34 | - | R | 1 … * | n | 1 … * R | An organ or part of an organ or a collection of parts sent to the laboratory under a unique (sub-)order identifier for trimming, blocking, cutting and staining |
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Group | Specimen | |||||||||||||
| Part ID | psr-dataelement-66 | - | R | 1 … 1 | 1 | 1 … 1 R Identifier | Identifier | <id root="1.3.6.1.4.1.19376.1.8.9.9" extension="A7102400008_A1"/> | Identifier of the part, issued by the LIS. It corresponds with the Order ID. |
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Item | Part | |||||||||||
| Block | psr-dataelement-35 | - | R | 0 … * | n | 0 … * R | A piece of tissue under a unique identifier resulting from trimming, embedded in paraffin or othe embedding media (usually FFPE ... Formalin-fixed, Paraffin-embedded). |
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Group | Part | |||||||||||||
| Block ID | psr-dataelement-67 | - | R | 1 … 1 | 1 | 1 … 1 R Identifier | Identifier | <id root="1.3.6.1.4.1.19376.1.8.9.9" extension="A7102400008_A1_1"/> | Identifier of the paraffin block, issued by the LIS as work order ID. In most cases identical with a container ID of the tissue cassette. |
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Item | Block | |||||||||||
| Tissue section | psr-dataelement-36 | - | R | 1 … * | n | 1 … * R |
A section of tissue on a glass-slide, mounted in medium and covered by a cover plate, carrying a unique identifier, resulting from cutting from a block with subsequent staining procedure
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Group | Block | |||||||||||||
| Tissue section ID | psr-dataelement-68 | - | R | 1 … 1 | 1 | 1 … 1 R Identifier | Identifier | <id root="1.3.6.1.4.1.19376.1.8.9.9" extension="A7102400008_A1_1_1HE"/> | Identifier of the slide, issued by the LIS. It corresponds with a Work order ID or a Specimen work order step ID |
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Item | Tissue section | |||||||||||
| Specimen identification | psr-dataelement-17 | - | R | 1 … 1 | 1 | 1 … 1 R | Identification of the specimen, done by identifiers, issued by the LIS. |
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Group | Specimen | |||||||||||||
| Container | psr-dataelement-70 | - | R | 0 … * | n | 0 … * R | Physical object that touches and holds specimen. Those may be vessels, syringes, plastic bags etc., especially important are Paraffin blocks and Slides. |
HL7 Domain Analysis Model: Specimen, Release 1, May 2014 |
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Specimen container [Type] (Logical Observation Identifier Names and Codes: 74384-9)
Specimen container (physical object) (SNOMED Clinical Terms: 434711009)
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Group | Specimen | ||||||||||||
| Procedure | psr-dataelement-23 | - | R | 1 … 1 | 1 | 1 … 1 R | Procedure performed to obtain or process specimens, or to make an observation. |
IHE_PAT_Suppl_APSR_Rev2 0_TI_2013_10_02 |
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Procedure (procedure) (SNOMED Clinical Terms: 71388002)
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Group | Anatomic Pathology Structured Report | ||||||||||||
| Device | psr-dataelement-79 | - | R | 0 … 1 | 1 | 0 … 1 R String | String | Device is any machinery in the pathology lab, which is used for procedures on, and both analyses and measurements of specimens for observations (IvD) |
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Item | Procedure | ||||||||||||
| Specimen collection | psr-dataelement-24 | - | R | 0 … * | n | 0 … * R Code | Code |
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Procedure performed by a clinician as to obtain a specimen for pathologic investigation. |
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Removal (procedure) (SNOMED Clinical Terms: 118292001)
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Specimen Collection and Processing 2016-05-31T15:09:59 (dynamic / Extensible/CWE)
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Item | Procedure | ||||||||||
| Specimen processing | psr-dataelement-25 | - | R | 0 … * | n | 0 … * R Code | Code |
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Procedure performed as to process a specimen in the lab. |
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Laboratory procedure (procedure) (SNOMED Clinical Terms: 108252007)
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Specimen Collection and Processing 2016-05-31T15:09:59 (dynamic / Extensible/CWE)
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Item | Procedure | ||||||||||
| Specimen Information Organizer | psr-dataelement-63 | - | NP | 0 … 0 | 0 … 0 NP Collection of data | Collection of data | It organizes information related to the various acts (procedures, observations) performed on a single specimen or group of specimens investigated together. | IHE_PAT_Suppl_APSR_Rev2 0_TI_2015_20_05 |
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cancelled |
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Item | Anatomic Pathology Structured Report | ||||||||||||
| ObservationReport | psr-dataelement-47 | - | R | 0 … * | n | 0 … * R | Report on the results of a human or machine procedure on one ore more observable entities that leads to one or more findings. |
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Group | Anatomic Pathology Structured Report | |||||||||||||
| Intraoperative observation | psr-dataelement-44 | - | R | 0 … 1 | 1 | 0 … 1 R | Intraoperative diagnosis for each specimen | IHE_PAT_Suppl_APSR_Rev2 0_TI_2013_10_02 |
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Group | ObservationReport | ||||||||||||
| intraoperative observation text | psr-dataelement-64 | - | R | 0 … 1 | 1 | 0 … 1 R Text | Text | intraoperative observation text |
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Item | Intraoperative observation | ||||||||||||
| Macroscopic observation | psr-dataelement-30 | - | R | 0 … 1 | 1 | 0 … 1 R | Observation performed by naked eye, including measurements |
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Group | ObservationReport | |||||||||||||
| macroscopic observation text | psr-dataelement-31 | - | R | 0 … 1 | 1 | 0 … 1 R Text | Text | macroscopic observation text |
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Item | Macroscopic observation | ||||||||||||
| Microscopic observation | psr-dataelement-15 | - | R | 0 … 1 | 1 | 0 … 1 R | Observation performed by using a microscope |
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Group | ObservationReport | |||||||||||||
| microscopic observation text | psr-dataelement-16 | - | R | 0 … 1 | 1 | 0 … 1 R Text | Text | detailed description of the microscopic observation |
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Item | Microscopic observation | ||||||||||||
| Diagnostic conclusion | psr-dataelement-45 | + | M | 1 … * | n | 1 … * M | Diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit from a single clinician (ordering provider) on a particular day. This is a critical summary of findings, giving an answer to the clinical question. The diagnoses for each specimen or group of specimens should be reported separately from each other. Additional pathologic finding(s) and the results of ancillary study(ies), diagrams and still images or virtual slides, if taken, may be included. In case of cancer, the tumor formula should be and any cancer checklist may be included. | IHE_PAT_Suppl_APSR_Rev2 0_TI_2015_20_05 |
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Group | ObservationReport | ||||||||||||
| Generic AP observation | psr-dataelement-65 | - | R | 0 … * | n | 0 … * R Code | Code | Atomic unit of a Generic AP observation, coded or as measurement value. Each generic observation must have a textual part for human readibility. |
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AP Observation 2015-11-22T12:20:34 (dynamic / Extensible/CWE)
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Item | Diagnostic conclusion | |||||||||||
| Embedded Image | psr-dataelement-71 | - | R | 0 … * | n | 0 … * R | Image of a specimen, or a schematic drawing, or part of a specimen, or a tissue section, embedded in an observation |
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Group | Diagnostic conclusion | |||||||||||||
| Image ID | psr-dataelement-69 | - | R | 1 … 1 | 1 | 1 … 1 R Identifier | Identifier | Identifier of the image, issued by the LIS (Order filler or Image manager) as Image ID. |
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Item | Embedded Image | ||||||||||||
| Microscopic Image | psr-dataelement-37 | - | R | 0 … * | n | 0 … * R Binary | Binary | Microscopic image (e.g. WSI) of a slide or part of a slide |
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Item | Embedded Image | ||||||||||||
| Scoring systems | psr-dataelement-57 | - | R | 0 … * | n | 0 … * R Code | Code | Systems for semiquantitative assessment of grading, (immunohistochemical) staining results, and other observable entities. |
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Assessment scales (assessment scale) (SNOMED Clinical Terms: 273249006)
Total Gleason score (observable entity) (SNOMED Clinical Terms: 384997002)
Nottingham Combined Grade (qualifier value) (SNOMED Clinical Terms: 372276001)
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Item | Diagnostic conclusion | ||||||||||||
| Tumor classification (ICD-O-3) | psr-dataelement-54 | - | R | 0 … * | n | 0 … * R | System for the classification of tumors according their site (location) and their histology (morphology). Hosted by WHO (IARC) in the ICD-O (International classification of diseases (oncology) | http://www.who.int/classifications/icd/adaptations/oncology/en/ | Classification structureA multi-axial classification of the site, morphology, behaviour, and grading of neoplasms.The topography axis uses the ICD-10 classification of malignant neoplasms (except those categories which relate to secondary neoplasms and to specified morphological types of tumours) for all types of tumours, thereby providing greater site detail for non-malignant tumours than is provided in ICD-10. In contrast to ICD-10, the ICD-O includes topography for sites of haematopoietic and reticuloendothelial tumours.The morphology axis provides five-digit codes ranging from 8000/0 to 9989/3. The first four digits indicate the specific histological term. The fifth digit after the slash (/) is the behaviour code, which indicates whether a tumour is malignant, benign, in situ, or uncertain (whether benign or malignant). A separate one-digit code is also provided for histologic grading (differentiation) or cell type in lymphomas and leukemias.A complete code consists of 10 digits (4 for topography, 6 for morphology, behavior and grading), separated by a "." after the 3rd digit in topography and a "/" after the 4th digit in morphology (8th digit in total). Qualifier for laterality (1 additional digit) may be given after the topography code. |
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Histology and Behavior ICD-O-3 Cancer (Logical Observation Identifier Names and Codes: 59847-4)
ICD-O-3 (International Classification of Diseases for Oncology: ICD-O: 2.16.840.1.113883.6.43.1)
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Group | Diagnostic conclusion | |||||||||||
| Topography (Tumor site) | psr-dataelement-73 | - | R | 0 … 1 | 1 | 0 … 1 R Code | Code | Indicates the tumor site. The topography axis of ICD-O-3 uses the ICD-10 classification of malignant neoplasms (except those categories which relate to secondary neoplasms and to specified morphological types of tumours) for all types of tumours, thereby providing greater site detail for non-malignant tumours than is provided in ICD-10. In contrast to ICD-10, the ICD-O includes topography for sites of haematopoietic and reticuloendothelial tumours. | http://www.who.int/classifications/icd/adaptations/oncology/en/ |
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Site coding system.current Cancer site (Logical Observation Identifier Names and Codes: 42129-7)
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ICD-O-3 Topography 2015-11-13T19:16:23 (dynamic)
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Item | Tumor classification (ICD-O-3) | ||||||||||
| Morphology (Typing) | psr-dataelement-56 | - | R | 0 … 1 | 1 | 0 … 1 R Code | Code | Classification of tumors according their morphology, resulting in tumor type. Classification System, part of ICD-O, hosted by WHO, published in the famous "blue books". Coded by the first 4 digits in the M chapter (Morphology axis) of ICD-O-3 (M-8000/0 to M-9989/3) |
http://www.who.int/classifications/icd/adaptations/oncology/en/ | Tumors are classified according their morphological properties, assuming that the morphology is an indicator for the original tissue component the tumor stems from. |
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Histology ICD-O-3 Cancer (Logical Observation Identifier Names and Codes: 31205-8)
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ICD-O-3 Morphology 2015-11-13T14:08:46 (dynamic)
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Item | Tumor classification (ICD-O-3) | |||||||||
| Behavior | psr-dataelement-72 | - | R | 0 … 1 | 1 | 0 … 1 R Code | Code |
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Indicates whether a tumour is malignant, benign, in situ, or uncertain (whether benign or malignant). Coded by the first digit after the slash in the M chapter (Morphology axis) of ICD-O-3 |
http://www.who.int/classifications/icd/adaptations/oncology/en/ |
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Behavior ICD-O-3 Cancer (Logical Observation Identifier Names and Codes: 31206-6)
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ICD-O-3 Behavior 2015-11-13T18:54:30 (dynamic)
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Item | Tumor classification (ICD-O-3) | |||||||||
| Differentiation | psr-dataelement-55 | - | R | 0 … 1 | 1 | 0 … 1 R | Differentiation means Grading as classification of tumors according their assumed grade of malignancy. The most often three-tiered grading system is used. Furthermore, the cell type of lympoproliferative neoplasias is classified in that system, too. Both are coded by the second digit after the slash in the M chapter (Morphology axis) of ICD-O-3 It also means differentiation according the lymphocyte type in malignant lymphomas. |
http://www.who.int/classifications/icd/adaptations/oncology/en/ | All grading systems share the assumption that a tumor is as more malignant as it differs morphologically from the original tissue. Highly differentiated tumors (very similar to the original tissue) are low malignant (low grade, grade 1), poorly differentiated tumors are highly malignant ones (high grade, grade 3 or 4). |
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Histological grade finding (finding) (SNOMED Clinical Terms: 373372005)
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Group | Tumor classification (ICD-O-3) | |||||||||||
| Assessment Scales (Score) | psr-dataelement-99 | - | C | 0 … 1 | 1 | 0 … 1 C Code | Code |
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Assessment scales or scores are a special, highly structured form of clinical findings (see scoring systems) |
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Assessment scales (assessment scale) (SNOMED Clinical Terms: 273249006)
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Item | Differentiation | ||||||||||
| Assessment Scales (Scores) | psr-dataelement-75 | - | C | 0 … 1 | 1 | 0 … 1 C | Assessment scales or scores are a special, highly structured form of clinical findings (see scoring systems) |
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cancelled |
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Group | Differentiation | ||||||||||||
| Tumor formula (TNM) | psr-dataelement-3 | - | R | 0 … * | n | 0 … * R | Tumor formula including T-, M- and N-values as well as further details (staging) and grading, well known as TNM classification, hosted by UICC | Sobin LH, Gospodarowicz MK, Wittekind Ch: TNM classification of malignant tumors.7th ed. 2010, 4th corrected postprint, Wiley&Sons |
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Pathologic TNM stage grouping (observable entity) (SNOMED Clinical Terms: 399588009)
Clinical TNM stage grouping (observable entity) (SNOMED Clinical Terms: 399537006)
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Group | Diagnostic conclusion | ||||||||||||
| Stage | psr-dataelement-74 | - | R | 0 … 1 | 1 | 0 … 1 R Code | Code | IVB |
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Stage system (hosted by UICC) of a tumor disease, compiling the elements of TNM classification |
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Stage group.pathology Cancer (Logical Observation Identifier Names and Codes: 21902-2)
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UICC Stage (7ed) 2015-06-23T16:43:02 (dynamic)
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Item | Tumor formula (TNM) | |||||||||
| Posttherapeutic | psr-dataelement-29 | - | R | 0 … 1 | 1 | 0 … 1 R Code | Code |
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Symbol for TNM: Is this Observation performed after a multimodal therapy? |
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y - During therapy/following treatment (tumor staging) (SNOMED Clinical Terms: 277649004)
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Item | Tumor formula (TNM) | |||||||||||
| Autopsy | psr-dataelement-28 | - | R | 0 … 1 | 1 | 0 … 1 R Code | Code |
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Symbol for TNM: Has this tumor formula been derived first at autopsy? |
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a - At autopsy (tumor staging) (SNOMED Clinical Terms: 277646006)
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Item | Tumor formula (TNM) | |||||||||||
| Postoperative | psr-dataelement-59 | - | R | 0 … 1 | 1 | 0 … 1 R Boolean | Boolean |
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Qualifier (prefix) for T, N, and M category: Is this Observation performed after operative therapy, i.e. information comes from the pathologist |
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p-pathological (1.2.276.0.76.3.1.131.1.5.1: tnmCp)
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Item | Tumor formula (TNM) | |||||||||||
| Clinical | psr-dataelement-60 | - | R | 0 … 1 | 1 | 0 … 1 R Code | Code |
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Qualifier (prefix) for T, N, and M category: Is this Observation performed by clinical methods? |
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draft |
c-clinical (1.2.276.0.76.3.1.131.1.5.1: tnmCp)
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TNM_Praefix_CP_UICC 2015-11-04T15:52:34 (dynamic)
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Item | Tumor formula (TNM) | |||||||||
| Multiplicity | psr-dataelement-61 | - | R | 0 … 1 | 1 | 0 … 1 R Code | Code | pT2(m); pT2(3) |
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Qualifier for pT category: Are there multiple tumors in the specimen removed or how many multiple tumors are in the specimen? |
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draft |
m-multiple tumors (1.2.276.0.76.3.1.131.1.5.1: tnmMultiplicity)
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UICC Multiplicity 2015-11-06T10:44:54 (dynamic)
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Item | Tumor formula (TNM) | |||||||||
| Multiple tumors (Multiplicity) | psr-dataelement-62 | - | NP | 0 … 0 | 0 … 0 NP Decimal number | Decimal number |
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pT2(3) | Qualifier for T category: Number of tumors more than one in the specimen removed. |
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cancelled |
number of multiple tumors (1.2.276.0.76.3.1.131.1.5.1: tnmMultiple)
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Item | Tumor formula (TNM) | |||||||||||
| Recurrence | psr-dataelement-26 | - | R | 0 … 1 | 1 | 0 … 1 R Code | Code |
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Symbol for TNM: Is this tumor recurring from a previous disease.. |
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draft |
r - Tumor recurrence (tumor staging) (SNOMED Clinical Terms: 277647002)
r (TNM Edition7 UICC: r)
r (TNM Edition6 UICC: r)
r (TNM Edition5 UICC: r)
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Item | Tumor formula (TNM) | |||||||||||
| Observation Timestamp | psr-dataelement-13 | - | R | 1 … 1 | 1 | 1 … 1 R Date/time | Date/time |
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point in time when this observation was made |
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draft |
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Item | Tumor formula (TNM) | |||||||||||
| Nodes Affected | psr-dataelement-12 | - | R | 0 … 1 | 1 | 0 … 1 R Quantity | Quantity | How many nodes are affected by tumor? |
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draft |
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Item | Tumor formula (TNM) | ||||||||||||
| Nodes Examined | psr-dataelement-11 | - | R | 0 … 1 | 1 | 0 … 1 R Quantity | Quantity | number of nodes examined |
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draft |
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Item | Tumor formula (TNM) | ||||||||||||
| Sentinel Lymph Nodes | psr-dataelement-102 | - | R | 0 … 1 | 1 | 0 … 1 R Code | Code | Regional lymph nodes according the sentinel concept: first draining lymph node for a tumor site |
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draft |
Specimen from sentinel lymph node (specimen) (SNOMED Clinical Terms: 441709004)
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Item | Tumor formula (TNM) | ||||||||||||
| N-category | psr-dataelement-8 | - | R | 0 … 1 | 1 | 0 … 1 R Code | Code |
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N-category (regional lymph nodes) of the TNM classification |
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draft |
Regional lymph nodes.pathology [Class] Cancer (Logical Observation Identifier Names and Codes: 21900-6)
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UICC N category 2017-07-21T10:00:53 (dynamic)
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Item | Tumor formula (TNM) | ||||||||||
| M-category | psr-dataelement-7 | - | R | 0 … 1 | 1 | 0 … 1 R Code | Code | M0, i.e. no distant metastases |
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M-category (distant metastases) of the TNM classification |
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draft |
Distant metastases.pathology [Class] Cancer (Logical Observation Identifier Names and Codes: 21901-4)
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UICC M category 2017-07-21T10:31:38 (dynamic)
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Item | Tumor formula (TNM) | |||||||||
| T-category | psr-dataelement-6 | - | R | 0 … 1 | 1 | 0 … 1 R Code | Code |
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T-category of the TNM classification |
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draft |
Primary tumor.pathology Cancer (Logical Observation Identifier Names and Codes: 21899-0)
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UICC T category 2017-07-07T15:06:39 (dynamic)
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Item | Tumor formula (TNM) | ||||||||||
| Residual tumor status | psr-dataelement-46 | - | R | 0 … 1 | 1 | 0 … 1 R Code | Code |
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Status of residual tumor after any therapy |
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draft |
Status of residual neoplasm (observable entity) (SNOMED Clinical Terms: 445200009)
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UICC Residual tumor (R) classification 2015-06-25T11:23:51 (dynamic)
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Item | Tumor formula (TNM) | ||||||||||
| Grading | psr-dataelement-53 | - | R | 0 … 1 | 1 | 0 … 1 R Code | Code |
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Method of histopathology to describe semiquantitatively resp. to classify the grade of differentiation / grade of malignancy of a malignant tumor. It results in four-tiered, three-tiered or two-tiered tumor grades. There is a tendency to reduce all systems to a two-tiered grading of low and high grade. | Large deviations from normal histoarchitecture, high pleomorphism of cells, and high proliferative activity correspond with a highly malignant behaviour. Low structural abnormalities, low pleomorphism and a low proliferative activity correspond with a rather good prognosis. This holds true for the vast majority of malignant tumors. |
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draft |
Histological grade finding (finding) (SNOMED Clinical Terms: 373372005)
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UICC Grade 4 tiered 2015-11-13T19:46:53 (dynamic)
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Item | Tumor formula (TNM) | |||||||||
| Problem Organizer | psr-dataelement-39 | - | R | 1 … * | n | 1 … * R |
The problem organizer groups the battery of observations performed to investigate on a single problem identified on a specimen or group of specimens. |
IHE_PAT_Suppl_APSR_Rev2 0_TI_2015_20_05 | The problem organizer is a mandatory entry for single or grouped atomic observations within an observation section. |
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draft |
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Group | Anatomic Pathology Structured Report | |||||||||||
| Clinician (Ordering Provider) | psr-dataelement-78 | - | R | 0 … 1 | 1 | 0 … 1 R String | String | The clinician is that medical professional who orders an pathologic examination (ordering provider), collects the specimen from the patient, and receives the pathology report. It is a role for a person |
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draft |
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Item | Anatomic Pathology Structured Report |