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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
1.3.6.1.4.1.19376.1.8.1.4.9
Gültigkeit ab
2014‑05‑14 17:09:54
Andere Versionen mit dieser Id:
APObservationEntry vom 2026‑08‑03 11:52:41
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 1.3.6.1.4.1.19376.1.8.1.4.9
Label
PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
Klassifikation
CDA Entry Level Template
Offen/Geschlossen
Offen (auch andere als die definierten Elemente sind erlaubt)
The Anatomic pathology observation code should be taken from a reference terminology, preferably the LOINC terminology. National terminologies may be used.
<codecode="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
PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
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 valueelement. In other cases the status of the intended observation is “aborted” and the result will never come.
PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
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
PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
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.
PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
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
<valuecode="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).
PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
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
PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
CONF
Der Wert von @code SOLLTE gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.14079 ObservationMethod (2014‑03‑26)
The performing laboratory is present at this level only if this particular observation was performed by a (subcontractor) laboratory distinct from the one issuing the rest of the observations in this organizer.
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)
PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
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.
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)
PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
@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> <idroot="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)
PaLM TF Suppl. APSR 2.1‑3: 6.3.5.5 AP observation
1.2 Zusammenstellung aller Versionen dieses Templates
Entwurf
