1.2.40.0.34.6.0.11.2.168

Weitere Informationen sind zusammengefasst im Hilfe-Beitrag Templates.

1 Template ClinicalInformationSection

The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, reason for anatomic pathology procedure, clinical laboratory data, specimen sent for investigation (including collection procedure, target site, performer, specimen type, specimen(s) clinical description, and tumor site in case of a cancer).

1.1 Aktuelle Version

Id	1.2.40.0.34.6.0.11.2.168	Gültigkeit ab	2026‑07‑17 09:25:28
Status	Entwurf	Versions-Label	1.0.0
Name	ClinicalInformationSection	Bezeichnung	Clinical Information Section
Beschreibung The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, reason for anatomic pathology procedure, clinical laboratory data, specimen sent for investigation (including collection procedure, target site, performer, specimen type, specimen(s) clinical description, and tumor site in case of a cancer).
Kontext	Elternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.2.168
Label	patho_section_ClinicalInformationSection
Klassifikation	CDA Section level template
Offen/Geschlossen	Geschlossen (nur definierte Elemente sind erlaubt)
Beziehung	Spezialisierung: Template 1.3.6.1.4.1.19376.1.8.1.2.1 Clinical Information Section (2014‑05‑13 14:38:08) ref psr- Spezialisierung: Template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07) ref ad1bbr-
Beispiel	generated example <section classCode="DOCSECT" moodCode="EVN">   <templateId root="1.3.6.1.4.1.19376.1.8.1.2.1"/>  <code code="22636-5" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report relevant history"/>  <title>CLINICAL INFORMATION SECTION</title>  <text/>  <languageCode/>  <entry xsi:type="ANY" typeCode="COMP" contextConductionInd="true">     <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) -->   </entry>  <!-- include template 1.3.6.1.4.1.19376.1.8.1.4.2 'CDA author IHE' (2016-06-21T14:02:11) 0..* C -->   <component>     <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.1 'IHE Reason for Referral Section' (2016-09-26T07:58:18) -->   </component>  <component>     <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.4 'History of Present Illness Section' (2013-01-31T00:00:00) -->   </component>  <component>     <!-- template 1.3.6.1.4.1.19376.1.5.3.1.3.6 'IHE Active Problems Section' (2015-10-05T16:02:07) -->   </component></section>
Item DT Kard Konf Beschreibung Label hl7:section 0 … 1 R path...tion @classCode cs 0 … 1 F DOCSECT @moodCode cs 0 … 1 F EVN   Constraint This section SHALL contain a code element populated with these attributes: @code="22636-5"  @codeSystem="'2.16.840.1.113883.6.1"  @displayName=" Pathology report relevant history”   This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader. The section SHOULD contain as many Problem Organizer entry elements as there are problems (or groups thereof) to be described. These entries provide the machine-readable data corresponding to the narrative block. This section MAY contain a number of elements component/section introducing sub-sections, each of these sub-sections providing a particular type of clinical information. This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document. hl7:templateId II 1 … 1 R path...tion @root uid 1 … 1 F 1.2.40.0.34.6.0.11.2.168 hl7:code CE 1 … 1 M path...tion @displayName st 0 … 1   @codeSystemName st 0 … 1 F LOINC @code CONF 1 … 1 F 22636-5 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (LOINC) hl7:title ST 1 … 1 R path...tion   CONF Elementinhalt MUSS "Überweisungsgrund" sein   Beispiel <title>CLINICAL INFORMATION</title> hl7:text SD.TEXT 1 … 1 M path...tion   Beispiel <text> Tissue submitted: left breast biopsy and apical axillary tissue </text>

1.2 Zusammenstellung aller Versionen dieses Templates

• 2026-07-17 09:25:28 (In Entwicklung)