1.2.40.0.34.6.0.11.2.170/static-2026-07-17T103533

Id	1.2.40.0.34.6.0.11.2.170	Gültigkeit ab	2026‑07‑17 10:35:33
Status	Entwurf	Versions-Label	2.0
Name	MicroscopySection	Bezeichnung	Microscopic Observation Section
Beschreibung The Microscopic Observation section contains optionally the histopathologic findings of the case and of all of its derived specimens. This section shpould be used to record the results of histochemical and immunohistochemical stains as well as of image-based molecular procedures.
Kontext	Elternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.2.170
Label	atpatho_section_MicroscopicObservationSection
Klassifikation	CDA Section level template
Offen/Geschlossen	Geschlossen (nur definierte Elemente sind erlaubt)
Beziehung	Spezialisierung: Template 1.3.6.1.4.1.19376.1.8.1.2.4 Microscopic Observation Section (2014‑05‑13 14:25:17) ref psr- Spezialisierung: Template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07) ref ad1bbr-
Beispiel	example from use case #1 <section classCode="DOCSECT">   <templateId root="1.3.6.1.4.1.19376.1.8.1.2.4"/>  <code code="22635-7" displayName="Pathology report microscopic observation" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <title>MICROSCOPIC OBSERVATION SECTION</title>  <!-- Text: Human-readable part -->   <text>      INVASIVE ADENOCARCINOMA OF THE BREAST.    <br/>     HISTOLOGIC TYPE: DUCTAL.    <br/>     NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3.     <list>       <item>TUBULE FORMATION SCORE: 2.</item>      <item>NUCLEAR PLEOMORPHISM SCORE: 2.</item>      <item>MITOTIC RATE SCORE: 1.</item>    </list>     IN-SITU CARCINOMA: EQUIVOCAL.    <br/>    <br/>     BREAST CANCER BIOMARKER STUDIES:     <list>       <item>PARAFFIN BLOCK NUMBER: A1.</item>      <item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8, Allred Percentage Score = 5, Allred Staining Score = 3).</item>      <item>PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED SCORE = 8).</item>      <item>DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.</item>      <item>HER2/NEU IMMUNOHISTOCHEMISTRY: EQUIVOCAL (2+) FOR OVEREXPRESSION OF HER2/NEU ONCOPROTEIN.</item>      <item>HER2/NEU FISH RESULTS: NOT AMPLIFIED.</item>    </list>  </text></section>
Item DT Kard Konf Beschreibung Label hl7:section 0 … 1 R atpa...tion   Constraint This section SHALL contain a code element populated with these attributes: @code ="22635-7" @codeSystem ="2.16.840.1.113883.6.1" @displayName ="Pathology report microscopic observation"  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 SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document. This section does not contain any subsections.  hl7:templateId II 1 … 1 M atpa...tion @root uid 1 … 1 F 1.2.40.0.34.6.0.11.2.170 hl7:code CE 1 … 1 M atpa...tion @code CONF 1 … 1 F 22635-7 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (LOINC) @codeSystemName 1 … 1 F LOINC @displayName 1 … 1 F Pathology report microscopic observation hl7:title ST 1 … 1 R atpa...tion   CONF Elementinhalt MUSS "Mikroskopie" sein   Beispiel <title>MICROSCOPIC OBSERVATION SECTION</title> hl7:text SD.TEXT 1 … 1 M atpa...tion   Beispiel example from use case#1 <text>    INVASIVE ADENOCARCINOMA OF THE BREAST.  <br/>   HISTOLOGIC TYPE: DUCTAL.  <br/>   NOTTINGHAM COMBINED HISTOLOGIC GRADE: 1 OF 3.   <list>     <item>TUBULE FORMATION SCORE: 2.</item>    <item>NUCLEAR PLEOMORPHISM SCORE: 2.</item>    <item>MITOTIC RATE SCORE: 1.</item>  </list>   IN-SITU CARCINOMA: EQUIVOCAL.  <br/>  <br/>   BREAST CANCER BIOMARKER STUDIES:   <list>     <item>PARAFFIN BLOCK NUMBER: A1.</item>    <item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8, Allred Percentage Score = 5, Allred Staining Score = 3).</item>    <item>PR INTERPRETATION: POSITIVE PROGESTERONE RECEPTOR ACTIVITY (ALLRED SCORE = 8).</item>    <item>DAKO EGFR PHARMDX IMMUNOHISTOCHEMISTRY: NEGATIVE (0) FOR EXPRESSION OF EPIDERMAL GROWTH FACTOR RECEPTOR.</item>    <item>HER2/NEU IMMUNOHISTOCHEMISTRY: EQUIVOCAL (2+) FOR OVEREXPRESSION OF HER2/NEU ONCOPROTEIN.</item>    <item>HER2/NEU FISH RESULTS: NOT AMPLIFIED.</item>  </list></text>