Entwurf| Beschreibung |
The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, reason for anatomic pathology procedure, clinical laboratory data, specimen sent for investigation (including collection procedure, target site, performer, specimen type, specimen(s) clinical description, and tumor site in case of a cancer). |
| Benutzt von 1 Transaction und 1 Template, Benutzt 3 Templates | ||||||||||||||||||||||||||||
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CDA Author (Body)ref
ad1bbr-
| Beispiel |
| <section> <templateId root="2.16.840.1.113883.3.1937.99.61.5.10.900275"/> <code code="22636-5" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report relevant history"/> <title/> <text/> <languageCode code=""/> <author> <!-- template CDAAuthorBody (dynamic) --> </author> <component> <!-- include template 2.16.840.1.113883.3.1937.99.61.5.10.900281 (dynamic) 0..* O--> </component> <component> <!-- include template 2.16.840.1.113883.3.1937.99.61.5.10.900282 (dynamic) 0..* O--> </component></section> |
| Item | DT | Kard | Konf | Beschreibung | Label | |
|---|---|---|---|---|---|---|
| hl7:section | 0 … * | APSR tion | ||||
| hl7:templateId | II | 1 … 1 | R | APSRtion | ||
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.3.1937.99.61.5.10.900275 | ||
| hl7:code | CE | 0 … 1 | APSRtion | |||
| @code | CONF | 0 … 1 | F | 22636-5 | ||
| @codeSystem | 0 … 1 | F | 2.16.840.1.113883.6.1 | |||
| @displayName | 0 … 1 | F | Pathology report relevant history | |||
| @codeSystemName | 0 … 1 | F | LOINC | |||
| hl7:title | ST | 0 … 1 | APSRtion | |||
| Beispiel | <title>CLINICAL INFORMATION</title> | |||||
| hl7:text | SD.TEXT | 0 … 1 | R | APSRtion | ||
| Beispiel | <text> Tissue submitted: left breast biopsy and apical axillary tissue </text> | |||||
| hl7:languageCode | CS | 0 … 1 | APSRtion | |||
| CONF |
| |||||
| hl7:author | 0 … * | Beinhaltet 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC) | APSRtion | |||
| hl7:component | 0 … * | APSRtion | ||||
| Eingefügt | 0 … * | von 2.16.840.1.113883.3.1937.99.61.5.10.900281 Reason for Referral Section (DYNAMIC) | ||||
| hl7:section | 0 … * | Reastion | ||||
| @classCode | cs | 0 … 1 | F | DOCSECT | ||
| @moodCode | cs | 0 … 1 | F | EVN | ||
| hl7:templateId | II | 1 … 1 | R | Reastion | ||
| @root | uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.3.1 | ||
| hl7:templateId | II | 1 … 1 | M | Reastion | ||
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.3.1937.99.61.5.10.900281 | ||
| hl7:code | CD | 1 … 1 | M | Reastion | ||
| @code | CONF | 1 … 1 | F | 42349-1 | ||
| @codeSystem | 1 … 1 | F | 2.16.840.1.113883.6.1 | |||
| hl7:title | ST | 1 … 1 | M | Reastion | ||
| Beispiel | <title>Reason for anatomic pathology procedure</title> | |||||
| hl7:text | SD.TEXT | 1 … 1 | M | Reastion | ||
| Beispiel | <text>Breast mass - left breast</text> | |||||
| hl7:component | 0 … * | APSRtion | ||||
| Eingefügt | 0 … * | von 2.16.840.1.113883.3.1937.99.61.5.10.900282 History of Present Illness Section (DYNAMIC) | ||||
| hl7:section | 0 … * | Histness | ||||
| @classCode | cs | 0 … 1 | F | DOCSECT | ||
| @moodCode | cs | 0 … 1 | F | EVN | ||
| hl7:templateId | II | 1 … 1 | R | Histness | ||
| @root | uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.3.4 | ||
| hl7:templateId | II | 1 … 1 | M | Histness | ||
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.3.1937.99.61.5.10.900282 | ||
| hl7:code | CD | 1 … 1 | M | Histness | ||
| @code | CONF | 1 … 1 | F | 10164-2 | ||
| @codeSystem | 1 … 1 | F | 2.16.840.1.113883.6.1 | |||
| hl7:title | ST | 1 … 1 | M | Histness | ||
| Beispiel | <title> History of present illness </title> | |||||
| hl7:text | SD.TEXT | 1 … 1 | M | Histness | ||
| Beispiel | <text>Carcinoma of breast. Post operative diagnosis: same. Left UOQ breast mass. </text> | |||||