1.2.40.0.34.6.0.11.3.197

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1 Template APObservationEntry

Template CDA Observation (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF). This Content Module is usable within a Problem Organizer. The “AP Observation” generic template is usable for all AP observations, including ancillary techniques. Each specific AP observation is associated to a specific template, child of the “AP Observation” generic template. This specific child template has exactly the same structure as the generic one, and brings only a number of vocabulary constraints related to the type of observation and to the type of organ source of the specimen observed:  The code for the specific observation, defined as a value set bound to the observation/code element, containing a single triplet (code, codeSystem, displayName) representing this specific observation. The cardinalities and default type for the observation/value element carrying the results of this observation. The domain of values for this observation in case these values are coded. This domain of coded values is defined as a value set bound to the observation/value element, containing as many triplets (code, codeSystem, displayName) as there are admissible result values for this specific observation performed on a specimen taken from this specific organ. An AP observation has a status and an effective time, may describe various participants (persons, devices, organizations), may have a number of additional properties (method, interpretation, text), and may contain embedded images, comments, and sub-observations, which are also AP observations.

1.1 Aktuelle Version

Id	1.2.40.0.34.6.0.11.3.197	Gültigkeit ab	2026‑08‑03 11:52:41 Andere Versionen mit dieser Id: APObservationEntry vom 2014‑05‑14 17:09:54
Status	Entwurf	Versions-Label	2.0
Name	APObservationEntry	Bezeichnung	AP Observation Entry
Beschreibung Template CDA Observation (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF). This Content Module is usable within a Problem Organizer. The “AP Observation” generic template is usable for all AP observations, including ancillary techniques. Each specific AP observation is associated to a specific template, child of the “AP Observation” generic template. This specific child template has exactly the same structure as the generic one, and brings only a number of vocabulary constraints related to the type of observation and to the type of organ source of the specimen observed:  The code for the specific observation, defined as a value set bound to the observation/code element, containing a single triplet (code, codeSystem, displayName) representing this specific observation. The cardinalities and default type for the observation/value element carrying the results of this observation. The domain of values for this observation in case these values are coded. This domain of coded values is defined as a value set bound to the observation/value element, containing as many triplets (code, codeSystem, displayName) as there are admissible result values for this specific observation performed on a specimen taken from this specific organ. An AP observation has a status and an effective time, may describe various participants (persons, devices, organizations), may have a number of additional properties (method, interpretation, text), and may contain embedded images, comments, and sub-observations, which are also AP observations.
Kontext	Elternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.3.197
Label	atpatho_entry_ApObservationEntry
Klassifikation	CDA Entry Level Template
Offen/Geschlossen	Geschlossen (nur definierte Elemente sind erlaubt)
Benutzt	Benutzt 10 Templates Benutzt als Name Version 1.2.40.0.34.6.0.11.9.24 Containment Performer - Laboratory (1.0.0+20211213) DYNAMIC 1.3.6.1.4.1.19376.1.8.1.4.2 Containment Author (2.0) 2016‑06‑21 14:02:11 1.3.6.1.4.1.19376.1.8.1.4.6 Containment Informant (2.0) 2016‑07‑08 11:22:58 1.3.6.1.4.1.19376.1.8.1.4.7 Containment Additional participant in an entry (2.0) 2016‑07‑12 18:44:06 1.3.6.1.4.1.19376.1.8.1.4.9 Containment AP Observation Entry (2.0) 2014‑05‑14 17:09:54 1.3.6.1.4.1.19376.1.8.1.4.10 Containment Embedded Image 2016‑06‑22 16:08:01 2.16.840.1.113883.10.12.307 Containment CDA RegionOfInterest 2005‑09‑07 1.3.6.1.4.1.19376.1.5.3.1.4.2 Containment IHE Comment Entry (2014) 2013‑12‑20 1.3.6.1.4.1.19376.1.3.10.9.1 Inklusion X Specimen Identified (2.0) 2014‑12‑22 15:54:30 2.16.840.1.113883.10.12.324 Containment CDA Reference 2005‑09‑07
Beziehung	Spezialisierung: Template 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54) ref psr- Spezialisierung: Template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07) ref ad1bbr-
Beispiel	Observation example for use case #1, estrogen receptor <observation classCode="OBS" moodCode="EVN" negationInd="false">   <templateId root="1.3.6.1.4.1.19376.1.8.1.4.9"/>  <id root="1.3.6.1.4.1.19376.1.8.9.1" extension="A7102400008_ER"/>  <code code="16112-5" codeSystem="2.16.840.1.113883.6.1" displayName="Estrogen receptor [Interpretation] in Tissue"/>  <statusCode code="completed"/>  <effectiveTime>     <low value="201001041405-0500"/>  </effectiveTime>  <value xsi:type="CD" code="416053008" displayName="Estrogen receptor positive tumor (disorder)" codeSystem="2.16.840.1.113883.6.96"/>  <methodCode code="0107" displayName="Microscopy" codeSystem="2.16.840.1.113883.5.84"/>  <performer>     <!-- template 1.3.6.1.4.1.19376.1.3.3.1.7 'CDA Performer IHE (Body)' (dynamic) -->   </performer>  <author>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author' (dynamic) -->   </author>  <informant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.6 'CDA Informant(Body) APSR2' (dynamic) -->   </informant>  <participant>     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.7 'Additional participant in an entry APSR (Body)' (dynamic) -->   </participant>  <entryRelationship xsi:type="" typeCode="COMP">     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.9 'AP Observation Entry' -->   </entryRelationship>  <entryRelationship xsi:type="" typeCode="COMP">     <!-- template 1.3.6.1.4.1.19376.1.8.1.4.10 'Embedded Image IHE' -->   </entryRelationship>  <entryRelationship xsi:type="" typeCode="COMP">     <!-- template 2.16.840.1.113883.10.12.307 'CDA RegionOfInterest' -->   </entryRelationship>  <specimen typeCode="SPC">     <specimenRole classCode="SPEC">       <id root="1.3.6.1.4.1.19376.1.8.9" extension="A7102400008_slide_A1_ER"/>    </specimenRole>  </specimen>  <reference>     <!-- template 2.16.840.1.113883.10.12.324 'CDA Reference' (dynamic) -->   </reference></observation>
Item DT Kard Konf Beschreibung Label hl7:observation 0 … * R atpa...ntry @classCode cs 1 … 1 F OBS @moodCode cs 1 … 1 F EVN @negationInd bl 0 … 1   hl7:templateId II 1 … 1 M atpa...ntry @root uid 1 … 1 F 1.2.40.0.34.6.0.11.3.197 hl7:id II 0 … * R atpa...ntry hl7:code CE (extensible) 1 … 1 M The Anatomic pathology observation code should be taken from a reference terminology, preferably the LOINC terminology. National terminologies may be used. atpa...ntry @code CONF 1 … 1 F each_code_for_observable_entities_or_a_specific_procedure @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (LOINC) @codeSystemName 1 … 1 F LOINC @displayName 1 … 1 F see_above   Beispiel <code code="59847-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Histology and Behavior ICD-O-3"/> hl7:text ED 0 … 1 R Narrative text about the observation atpa...ntry hl7:statusCode CS (erforderlich) 1 … 1 M The observation statusCode is “completed” if the observation was actually performed and has produced a result in the  value element. In other cases the status of the intended observation is “aborted” and the result will never come. atpa...ntry   Constraint @code shall be "completed" or @code shall be "aborted"   CONF Der Wert von @code MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.15933 ActStatus (2014‑03‑26) hl7:effectiveTime IVL_TS 1 … 1 M Date and time the observation has been made atpa...ntry hl7:value ANY 0 … * R Observation values using the appropriate data type. Numeric results use data type PQ, which includes the unit. The result is absent in case of ‘aborted’ observation. atpa...ntry   Constraint The default data type, cardinalities and value set for the <value> element are dependant on the type of observation.   CONF Der Wert von @code MUSS gewählt werden aus dem Value Set 1.3.6.1.4.1.19376.1.3.11.11 AP Observation (2015‑11‑22 12:20:34)   Beispiel for observation on tumor type <value code="8500/3" codeSystem="2.16.840.1.113883.6.43.1" codeSystemName="ICD-O-3" displayName="Invasive carcinoma of the breast, no special type"/> hl7:interpretationCode CE (extensible) 0 … 1 R One or more codes interpreting the result, expressed with ObservationInterpretation vocabulary (e.g., H = high, L = low).  This element may be coded with other values than those of the ObservationInterpretation vocabulary, given that the coding strength is CWE (coded with exceptions). atpa...ntry   CONF Der Wert von @code SOLLTE gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.78 ObservationInterpretation (2014‑03‑26) hl7:methodCode CE (extensible) 0 … 1 R atpa...ntry   CONF Der Wert von @code SOLLTE gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.14079 ObservationMethod (2014‑03‑26) hl7:performer II 0 … 1 R Performing lab Source:  PaLM TF-3: 6.3.2.20 Beinhaltet 1.2.40.0.34.6.0.11.9.24 Performer - Laboratory (DYNAMIC) atpa...ntry hl7:author II 0 … * C Author Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.2 Beinhaltet 1.3.6.1.4.1.19376.1.8.1.4.2 Author (2016‑06‑21 14:02:11) atpa...ntry hl7:informant II 0 … * R Informant Source:  PaLM TF Suppl. APSR 2.0-3 : 6.3.6.5 Beinhaltet 1.3.6.1.4.1.19376.1.8.1.4.6 Informant (2016‑07‑08 11:22:58) atpa...ntry hl7:participant II 0 … * R Additional participants Source:  PaLM TF Suppl. APSR 2.0-3 : 6.3.6.6 Beinhaltet 1.3.6.1.4.1.19376.1.8.1.4.7 Additional participant in an entry (2016‑07‑12 18:44:06) atpa...ntry hl7:entryRelationship 0 … * R Sub-Observation The result obtained for an observation may lead to an additional AP observation to refine this result. This sub-observation is again an Anatomic Pathology Observation. Source: Source: PaLM TF Suppl. APSR 2.0-3: 6.3.6.7 Beinhaltet 1.3.6.1.4.1.19376.1.8.1.4.9 AP Observation Entry (2014‑05‑14 17:09:54) atpa...ntry @typeCode cs 1 … 1 F COMP hl7:entryRelationship 0 … * R Embedded image.  This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest.  Source:  PaLM TF Suppl. APSR 2.0-3 : 6.3.6.8 Beinhaltet 1.3.6.1.4.1.19376.1.8.1.4.10 Embedded Image (2016‑06‑22 16:08:01) atpa...ntry @typeCode cs 1 … 1 F COMP hl7:entryRelationship 0 … * R Region of Interest Beinhaltet 2.16.840.1.113883.10.12.307 CDA RegionOfInterest (2005‑09‑07) atpa...ntry @typeCode cs 1 … 1 F COMP   Constraint This observation may carry an illustrative image, either directly embedded or encapsulated within a region of interest. In the latter case by an entryRelationship @typeCode="SUBJ" hl7:entryRelationship 0 … * R Annotation comment Beinhaltet 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (2013‑12‑20) atpa...ntry @typeCode cs 0 … 1 F COMP Eingefügt 1 … * M von 1.3.6.1.4.1.19376.1.3.10.9.1 X Specimen Identified (2014‑12‑22 15:54:30) Specimen identification   Beispiel Example for specimen referencing <specimen>   <!-- which specimen is used for this observation -->   <specimenRole>     <id root="1.3.6.1.4.1.19376.1.8.1.4.999999" extension="slide_A_1_PR"/>  </specimenRole></specimen> hl7:specimen 1 … * M Required in XD-LAB when more than one specimen is documented at this level. Always required in APSR. PaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified @typeCode cs 0 … 1 F SPC hl7:specimenRole 1 … 1 M PaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified @classCode cs 0 … 1 F SPEC hl7:id II 1 … 1 R Specimen ID, coming from the LIS PaLM Suppl. APSR 2.1‑3: 6.3.5.7 X Specimen identified hl7:reference 0 … * R Reference to an external document, or to external observations, e.g. concerning molecular pathology or  genetic testing report Beinhaltet 2.16.840.1.113883.10.12.324 CDA Reference (2005‑09‑07) atpa...ntry

1.2 Zusammenstellung aller Versionen dieses Templates

• 2026-08-03 11:52:41 (In Entwicklung)