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# Template IPS Pathology Result Observation

Id | 2.16.840.1.113883.10.22.4.11 | Effective Date | 2024‑08‑04 11:10:42
Status | Draft | Version Label | STU2
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 | IPS Result Organizer (STU1) | 2017‑03‑02
2.16.840.1.113883.10.22.3.14 |  | IPS Results Section (STU1) | 2017‑04‑30
2.16.840.1.113883.10.22.1.2 |  | International Patient Summary (2024) | 2024‑08‑02 13:02:39
Uses | as | Name | Version
2.16.840.1.113883.10.22.4.14 | Include | IPS Body Author (STU1) | DYNAMIC
2.16.840.1.113883.10.22.4.22 | Containment | IPS Comment Activity (STU1) | DYNAMIC
Relationship | Specialization: template 2.16.840.1.113883.10.22.4.11 IPS Pathology Result Observation (2017‑03‑21) Adaptation: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07) ref ad1bbr- Adaptation: template 2.16.840.1.113883.10.20.22.4.2 Result Observation (V3) (2015‑08‑01) ref ccda- Adaptation: template 2.16.840.1.113883.10.22.4.10 IPS Result Observation (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"/> </code></observation>
Item | DT | Card | Conf | Description | Label
--- | --- | --- | --- | --- | ---
hl7:observation |  |  |  |  |
@classCode | cs | 1 … 1 | F | OBS
@moodCode | cs | 1 … 1 | F | EVN
hl7:templateId | II | 1 … 1 | M |  |
@root | uid | 1 … 1 | F | 2.16.840.1.113883.10.22.4.11
hl7:id | II | 0 … * | R |  |
hl7:code | CD.IPS | 1 … 1 | M |  |
| CONF |
The value of @code SHALL be drawn from value set 2.16.840.1.113883.11.22.75 IPS Results Laboratory/Pathology Observation (DYNAMIC)
hl7:statusCode | CS | 1 … 1 | M |  |
| 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 |  |
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 |  |
where [@xsi:type='CE.IPS'] |
| CONF |
The value of @code SHOULD be drawn from value set 2.16.840.1.113883.11.22.74 IPS Results Coded Values Laboratory/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 |  |
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 |  |
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 |  |
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 |  |
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 |  |
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 |  |
| CONF |
The value of @code SHALL be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)
Included | 0 … * | R | from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
hl7:author |  | 0 … * | R |  |
hl7:templateId | II | 1 … 1 | M |  |
@root | uid | 1 … 1 | F | 2.16.840.1.113883.10.22.4.14
hl7:time | TS.IPS.TZ | 1 … 1 | R |  |
hl7:assignedAuthor |  | 1 … 1 | M |  |
hl7:id | II | 1 … * | R |  |
hl7:code |  | 0 … 1 | R |  |
Choice | 0 … 1 |  | Elements to choose from: hl7:assignedPerson hl7:assignedAuthoringDevice
hl7:assignedPerson |  | 0 … 1 | C |  |
@classCode | cs | 0 … 1 | F | PSN
@determinerCode | cs | 0 … 1 | F | INSTANCE
hl7:name | PN | 1 … * | R | Name of the person (e.g. the Healthcare Professional) authoring this document |
| Example | <name> <given>John</given> <family>Español Smith</family></name>
hl7:family |  | 1 … * | R |  |
hl7:given |  | 1 … * | R |  |
hl7:assignedAuthoringDevice |  | 0 … 1 | C |  |
| Example | <assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE"> <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included |  |  | from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
@classCode | cs | 0 … 1 | F | DEV
@determinerCode | cs | 0 … 1 | F | INSTANCE
hl7:code | CE | 0 … 1 |  |  |
hl7:manufacturerModelName | SC | 0 … 1 |  |  |
hl7:softwareName | SC | 0 … 1 |  |  |
hl7:representedOrganization |  | 0 … 1 |  |  |
hl7:id | II | 0 … * |  |  |
hl7:name |  | 0 … * |  |  |
hl7:telecom | TEL | 0 … * |  |  |
hl7:addr | AD | 0 … * |  |  |
hl7:referenceRange |  | 0 … * | R |  |
hl7:observationRange |  | 1 … 1 | M |  |
hl7:code | CD |  | NP |  |
hl7:value | ANY | 1 … 1 | M |  |
hl7:interpretationCode | CE | 0 … 1 |  |  |
@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) |
@typeCode | cs | 1 … 1 | F | COMP