example for use case #1, problem: invasive breast cancer
<organizerclassCode="BATTERY"moodCode="EVN"> <templateIdroot="1.3.6.1.4.1.19376.1.8.1.3.6"/><idroot="1.3.6.1.4.1.19376.1.8.9.1"extension="A7102400008_Problem1"/><codecode="75326-9"codeSystem="2.16.840.1.113883.6.1"displayName="Problem"/><statusCodecode="completed"/><effectiveTime> <lowvalue="201001041605-0500"/></effectiveTime><!--The problem is expressed by the result of the observation having the same code as organizer/code--> <component> <observationclassCode="OBS"moodCode="EVN"> <codecode="75326-9"codeSystem="2.16.840.1.113883.6.1"displayName="Problem"/><valuecode="C50.9"codeSystem="2.16.840.1.113883.6.3"displayName="Malignant neoplasm of breast, unspecified"codeSystemDisplayName="ICD-10"/></observation></component><componenttypeCode="COMP"contextConductionInd="true"> <sequenceNumbervalue="1"/><!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' (2014-05-14T17:09:54) --> </component><reference> <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (2005-09-07T00:00:00) --> </reference></organizer>
Item
DT
Kard
Konf
Beschreibung
Label
hl7:organizer
0 … *
R
Problem organizer groups the observations and images investigating a single problem related to one or more specimens
atpa...izer
@classCode
cs
1 … 1
F
BATTERY
@moodCode
cs
1 … 1
F
EVN
hl7:templateId
II
1 … 1
M
atpa...izer
@root
uid
1 … 1
F
1.2.40.0.34.6.0.11.3.194
hl7:id
II
0 … *
R
atpa...izer
hl7:code
CD (erforderlich)
0 … 1
R
Problem
atpa...izer
@displayName
st
0 … 1
@codeSystemName
st
1 … 1
F
LOINC
@code
CONF
1 … 1
F
75326-9
@codeSystem
1 … 1
F
2.16.840.1.113883.6.1 (LOINC)
hl7:statusCode
CS (erforderlich)
1 … 1
M
The status of the organizer is " completed" if the battery of observations for this problem has been performed. It is " aborted" in case some of the intended observations could not be achieve and have been aborted, and appear as such below the organizer.
atpa...izer
Constraint
@code shall be "completed"
or
@code shall be "aborted"
@code
CONF
1 … 1
F
completed
hl7:effectiveTime
IVL_TS
1 … 1
M
Organizer time.
The period of time (possibly reduced to a point in time) during which the information was collected and assembled.
atpa...izer
hl7:performer
0 … 1
R
Performing lab.
The performing laboratory is present at this level only if this particular problem on this particular specimen was investigated by a (subcontractor) distinct laboratory from the one issuing the consolidated report
von 1.2.40.0.34.6.0.11.9.69 X Specimen Identified (DYNAMIC) Specimen identification outside an AP observation for differentiating or restituting the problem type
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.9
hl7:specimen
0 … *
R
Required in XD-LAB when more than one specimen is documented at this level. Always required in APSR.
atpa...fied
@typeCode
cs
0 … 1
F
SPC
hl7:specimenRole
1 … 1
M
atpa...fied
@classCode
cs
0 … 1
F
SPEC
hl7:id
II
1 … 1
R
Specimen ID, coming from the LIS
atpa...fied
hl7:component
0 … 1
R
Coding of the Problem reported
atpa...izer
@typeCode
cs
1 … 1
F
COMP
hl7:observation
0 … 1
R
atpa...izer
hl7:code
CD (extensible)
1 … 1
R
atpa...izer
@code
CONF
0 … 1
F
75326-9
@codeSystem
0 … 1
F
2.16.840.1.113883.6.1 (LOINC)
@codeSystemName
0 … 1
F
LOINC
@displayName
0 … 1
F
Problem
hl7:value
CE (extensible)
0 … 1
R
Code of the problem reported
atpa...izer
CONF
@code MUSS "any_code" sein
@codeSystem MUSS "2.16.840.1.113883.6.3" sein
@codeSystemName MUSS "any_code" sein
@displayName MUSS "ICD-10" sein
oder
Der Wert von @code SOLLTE gewählt werden aus dem Value Set 1.3.6.1.4.1.19376.1.3.11.7 Problem Type (2016‑07‑11 09:52:19)
hl7:component
0 … *
R
Any kind of AP observation, for complex observations, e.g. for TNM, ICD-O-3, or Assessment scales, the appropriate templates may be used.
Source: PaLM Suppl. APSR 2.0-3: 6.3.6.7
Beinhaltet 1.2.40.0.34.6.0.11.3.197 AP Observation Entry (DYNAMIC)