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draft Template  IPS Pathology Result Observation

Id 2.16.840.1.113883.10.22.4.11 Effective Date 2017‑03‑21
Status draft Draft Version Label
Name IPSPathologyResultObservation Display Name IPS Pathology Result Observation
Description
This template constrains the results of an  anatomic pathology observation. The result observation includes a statusCode to allow recording the status of an observation. “Pending” results (e.g., a test has been run but results have not been reported yet) should be repnresented as “active” ActStatus.
Context Parent nodes of template element with id 2.16.840.1.113883.10.22.4.11
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 3 templates, Uses 2 templates
Used by as Name Version
2.16.840.1.113883.10.22.4.9 Containment draft IPS Result Organizer 2017‑03‑02
2.16.840.1.113883.10.22.3.14 link draft IPS Results Section 2017‑04‑30
2.16.840.1.113883.10.22.1.1 link draft International Patient Summary 2017‑04‑11
Uses as Name Version
2.16.840.1.113883.10.22.4.14 Containment draft IPS Body Author DYNAMIC
2.16.840.1.113883.10.22.4.22 Containment draft IPS Comment Activity DYNAMIC
Relationship Adaptation: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Adaptation: template 2.16.840.1.113883.10.20.22.4.2 (2015‑08‑01)
Adaptation: template 2.16.840.1.113883.10.22.4.10 (2017‑03‑02)
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.22.4.11"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="44638-5" codeSystem="2.16.840.1.113883.6.1" displayName="Histologic type in Breast tumor by CAP cancer protocols"/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20171210085407"/>  </effectiveTime>  <value xsi:type="CD" code="399935008" displayName="Ductal carcinoma in situ - category (morphologic abnormality)" codeSystem="2.16.840.1.113883.6.96"/>  <methodCode code="104157003" displayName="Light microscopy" codeSystem="2.16.840.1.113883.6.96"/></observation>
Item DT Card Conf Description Label
hl7:observation
 (IPSdotsion)
@classCode
 cs 1 … 1 F OBS
@moodCode
 cs 1 … 1 F EVN
hl7:templateId
 II 1 … 1 M (IPSdotsion)
@root
 uid 1 … 1 F 2.16.840.1.113883.10.22.4.11
hl7:id
 II 0 … * R (IPSdotsion)
hl7:code
 CD.IPS 1 … 1 M (IPSdotsion)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.41 IPS Results Observation Pathology (DYNAMIC)
hl7:statusCode
 CS 1 … 1 M (IPSdotsion)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC)
hl7:effectiveTime
 IVL_TS 1 … 1 R (IPSdotsion)
Choice 1 … 1 Elements to choose from:
  • hl7:value[@xsi:type='CE.IPS']
  • hl7:value[@xsi:type='PQ']
  • hl7:value[@xsi:type='IVL_PQ']
  • hl7:value[@xsi:type='ST']
  • hl7:value[@xsi:type='TS']
  • hl7:value[@xsi:type='RTO_QTY_QTY']
hl7:value
 CE.IPS (extensible) 0 … 1 R (IPSdotsion)
treeblank treeblank where [@xsi:type='CE.IPS']
  CONF
The value of @code should be drawn from value set 2.16.840.1.113883.11.22.47 IPS Results Coded Values Pathology (DYNAMIC)
  Example
Result code: code '201' from code system 2.16.840.1.113883.2.4.4.30.1045
<value xsi:type="CE" code="399935008" displayName="Ductal carcinoma in situ - category (morphologic abnormality)" codeSystem="2.16.840.1.113883.6.96"/>
  Example
Result code: code 'POS' from code system 2.16.840.1.113883.5.83
<value xsi:type="CE" code="369790002" displayName="Nottingham Combined Grade I: 3-5 points (finding)" codeSystem="2.16.840.1.113883.6.96"/>
hl7:value
 PQ 0 … 1 R (IPSdotsion)
treeblank treeblank where [@xsi:type='PQ']
  Constraint If Observation/value is a physical quantity (xsi:type="PQ"), the unit of measure SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive 2.16.840.1.113883.1.11.12839 DYNAMIC
  Example
Result physical quantity (data type PQ): 136 mmol per liter
<value xsi:type="PQ" value="85" unit="%"/>
hl7:value
 IVL_PQ 0 … 1 R (IPSdotsion)
treeblank treeblank where [@xsi:type='IVL_PQ']
  Example
Result interval of physical quantities (data type IVL_PQ): 150 - 400 Billion per 10 exp 9 liter
<value xsi:type="IVL_PQ">
  <low value="150" unit="10+9/l"/>  <high value="400" unit="10+9/l"/></value>
hl7:value
 ST 0 … 1 R (IPSdotsion)
treeblank treeblank where [@xsi:type='ST']
  Example
Result free text (data type ST)
<value xsi:type="ST">This is a result as a free text</value>
hl7:value
 TS 0 … 1 R (IPSdotsion)
treeblank treeblank where [@xsi:type='TS']
  Example
Result time stamp (data type TS): 6-Aug-2014
<value xsi:type="TS" value="20140806"/>
hl7:value
 RTO_QTY_QTY 0 … 1 R (IPSdotsion)
treeblank treeblank where [@xsi:type='RTO_QTY_QTY']
  Example
Result ratio (data type RTO_QTY_QTY): 1/179
<value xsi:type="RTO_QTY_QTY">
  <numerator xsi:type="INT" value="1"/>  <denominator xsi:type="INT" value="179"/></value>
hl7:interpretationCode
 CE.IPS 0 … 1 R (IPSdotsion)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)
hl7:author
 0 … * R Contains 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC) (IPSdotsion)
treeblank where [hl7:templateId [@root = '2.16.840.1.113883.10.22.4.14']]
hl7:referenceRange
 0 … * R (IPSdotsion)
hl7:observationRange
 1 … 1 M (IPSdotsion)
hl7:code
 CD NP (IPSdotsion)
hl7:value
 ANY 1 … 1 M (IPSdotsion)
hl7:interpretationCode
 CE 0 … 1 (IPSdotsion)
@code
 CONF 0 … 1 F N
@codeSystem
 0 … 1 F 2.16.840.1.113883.5.83 (Observation Interpretation)
hl7:entryRelationship
 0 … * Contains 2.16.840.1.113883.10.22.4.22 IPS Comment Activity (DYNAMIC) (IPSdotsion)
treeblank where [hl7:act [hl7:templateId [@root = '2.16.840.1.113883.10.22.4.22']]]
@typeCode
 cs 1 … 1 F COMP