Id2.16.840.1.113883.3.1937.99.61.5.10.900283Gültigkeit ab2014‑07‑29 16:02:02
Statusdraft EntwurfVersions-Label
NameCDAProcedureBezeichnungAPSR2 Specimen procedure step Entry
Beschreibung
Template CDA Procedure (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF)
for Specimen procedure step in APSR2.

This entry collects all the information of source, method and result of a specimen procedure from the collection out of the patient through the final product of a stained histologic section or cytologic smear on a glass slide, or a WSI of such a slide. It reflects the workflow and the probe tracking of a pathology laboratory.

KontextElternknoten des Template-Element mit Id 2.16.840.1.113883.3.1937.99.61.5.10.900283
KlassifikationCDA Entry Level Template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Benutzt von / Benutzt
Benutzt von 1 Transaction und 3 Templates, Benutzt 4 Templates
Benutzt von als NameVersion
2.16.840.1.113883.3.1937.99.61.5.4.22Transaktiondraft CDA Document APSR22014‑11‑16 11:45:10
2.16.840.1.113883.3.1937.99.61.5.10.900222Containmentretired eLab_Spezimen-Act2013‑12‑05 11:40:39
2.16.840.1.113883.3.1937.99.61.5.10.900273linkdraft Anatomic Pathology Structured Report2014‑05‑13 11:57:57
2.16.840.1.113883.3.1937.99.61.5.10.900279Containmentdraft APSR2 Procedure Steps Section2014‑05‑13 19:33:12
Benutzt als NameVersion
2.16.840.1.113883.3.1937.99.61.5.10.900224Containmentdraft eLab_CDA Performer (Body)DYNAMIC
2.16.840.1.113883.3.1937.99.61.5.10.900284Inklusiondraft CDA Participant (Body) APSRDYNAMIC
2.16.840.1.113883.10.12.318Containmentactive CDA Author (Body)DYNAMIC
2.16.840.1.113883.10.12.322Containmentactive CDA SpecimenDYNAMIC
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.306 CDA Procedure (2005‑09‑07)
ref
ad1bbr-
Beispiel
Specimen procedure step entry
<procedure negationInd="false" classCode="PROC" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.12.306"/>  <templateId root="2.16.840.1.113883.3.1937.99.61.5.10.900283"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="17636008" codeSystem="2.16.840.1.113883.6.96" displayName="Specimen collection (procedure)"/>  <text/>  <statusCode code="normal"/>  <effectiveTime>
    <low value="20141226122646"/>  </effectiveTime>  <methodCode/>  <targetSiteCode/>  <specimen>
    <!-- template 2.16.840.1.113883.10.12.322 (dynamic) -->
  </specimen>  <performer>
    <!-- template CDAPerformerBody (dynamic) -->
  </performer>  <author>
    <!-- template CDAAuthorBody (dynamic) -->
  </author>  <participant>
    <!-- include template 2.16.840.1.113883.3.1937.99.61.5.10.900284 (dynamic) 1..1 M-->
  </participant></procedure>
ItemDTKardKonfBeschreibungLabel
hl7:procedure
1 … *RCDAPdotsdure
@classCode
cs1 … 1FPROC
@moodCode
cs1 … 1FEVN
@negationInd
bl0 … 1 
hl7:templateId
II1 … 1RCDAPdotsdure
@root
uid1 … 1F2.16.840.1.113883.10.12.306
hl7:templateId
II1 … 1MCDAPdotsdure
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.5.10.900283
hl7:id
II0 … *CDAPdotsdure
hl7:code
CD1 … 1RCDAPdotsdure
 Constraintfor specimen collection procedure codes for targetSite or PathLex or SNOMED CT have to be used, for specimen processing (down step the procedures) SNOMED CT is preferred, DICOM could be used if available
 CONF
@code muss "17636008" sein
@codeSystem muss "2.16.840.1.113883.6.96" sein
@displayName muss "Specimen collection (procedure)" sein
@codeSystemName muss "SNOMED CT" sein
oder
@code muss "40923002" sein
@codeSystem muss "2.16.840.1.113883.6.96" sein
@displayName muss "Tissue processing technique, routine, embed, cut and stain, per surgical specimen (procedure)" sein
@codeSystemName muss "SNOMED CT" sein
hl7:text
ED0 … 1CDAPdotsdure
 Beispiel
specimen (collection/processing) procedure
<text>ULTRASOUND GUIDED NEEDLE CORE BIOPSY</text>
hl7:statusCode
CS0 … 1CDAPdotsdure
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
hl7:effectiveTime
IVL_TS0 … 1CDAPdotsdure
hl7:methodCode
CE0 … *CDAPdotsdure
@codeSystem
CONF0 … 1F2.16.840.1.113883.5.1065
hl7:targetSiteCode
CD0 … *CDAPdotsdure
@codeSystem
CONF0 … 1F2.16.840.1.113883.5.1052
hl7:specimen
0 … *Beinhaltet 2.16.840.1.113883.10.12.322 CDA Specimen (DYNAMIC)CDAPdotsdure
hl7:performer
0 … *Beinhaltet 2.16.840.1.113883.3.1937.99.61.5.10.900224 eLab_CDA Performer (Body) (DYNAMIC)CDAPdotsdure
hl7:author
0 … *Beinhaltet 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)CDAPdotsdure
hl7:participant
0 … 1CDAPdotsdure
Eingefügt1 … 1M von 2.16.840.1.113883.3.1937.99.61.5.10.900284 CDA Participant (Body) APSR (DYNAMIC)
 Beispiel
Specimen collected or processed
<participant typeCode="PRD">
  <participantRole classCode="SPEC">
    <!-- specimen ids -->
    <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="A7102400008"/>    <playingEntity>
      <!-- need a code in PATHLEX for "part obtained from a biopsy -->
      <code code="theCode" codeSystem="1.3.6.1.4.1.19376.1.8.2.1" displayName="part collected by biopsy" codeSystemName="PATHLEX"/>    </playingEntity>  </participantRole></participant>
@typeCode
cs1 … 1FPRD
@contextControlCode
cs1 … 1FOP
hl7:time
IVL_TS1 … 1MCDAPdotsPSR2
hl7:participantRole
1 … 1MCDAPdotsPSR2
@classCode
cs0 … 1FSPEC
hl7:id
II1 … 1MCDAPdotsPSR2
hl7:id
II1 … 1MCDAPdotsPSR2
 ConstraintThis Id is the paraentId, i.e. the id of the parent of this specimen
hl7:code
CE0 … 1CDAPdotsPSR2
@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111
Eingefügt von 2.16.840.1.113883.3.1937.99.61.5.10.900285 CDA PlayingEntity APSR2 (DYNAMIC)
@classCode
cs0 … 1FENT
@determinerCode
cs0 … 1FINSTANCE
hl7:code
CE0 … 1Codes for
- classCode
- typeCode
- subTypeCode
- isDerived
- specimenRole
- specimenChildRole
- specimenGroupCount		CDAPdotsPSR2
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.16040 EntityCode (DYNAMIC)
oder
@code muss "see example " sein
oder
@code muss "119376003" sein
@codeSystem muss "2.16.840.1.113883.6.96" sein
@displayName muss "Tissue, unspecified" sein
@codeSystemName muss "SNOMED-CT" sein
oder
@code muss "TISS" sein
@codeSystem muss "2.16.840.1.113883.5.129" sein
@codeSystemName muss "HL7" sein
 Beispiel
example for PathLex
<playingEntity>
  <!-- Need codes in PathLex for "part obtained by e.g.biopsy" -->
  <code code="theCode" codeSystem="1.3.6.1.4.1.19376.1.8.2.1" displayName="part collected by e.g.biopsy" codeSystemName="PathLex"/></playingEntity>
hl7:quantity
PQ0 … *CDAPdotsPSR2
hl7:name
PN0 … *CDAPdotsPSR2
hl7:desc
ED0 … 1CDAPdotsPSR2