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1 Template DiagnosticConclusionSection
The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary
study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.
1.1 Aktuelle Version
Id
1.2.40.0.34.6.0.11.2.171
Gültigkeit ab
2026‑07‑17 12:33:29
Status
Entwurf
Versions-Label
2.0
Name
DiagnosticConclusionSection
Bezeichnung
Diagnostic Conclusion Section
Beschreibung
The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary
study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.
Kontext
Elternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.2.171
Label
atpatho_section_DiagnosticConclusionSection
Klassifikation
CDA Section level template
Offen/Geschlossen
Geschlossen (nur definierte Elemente sind erlaubt)
<sectionclassCode="DOCSECT"> <templateIdroot="1.3.6.1.4.1.19376.1.8.1.2.5"/><codecode="22637-3"displayName="Pathology report final diagnosis"codeSystem="2.16.840.1.113883.6.1"codeSystemName="LOINC"/><title>DIAGNOSTIC CONCLUSION SECTION</title><text> <paragraph> A1. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY)</paragraph> 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> ICD-O-CLASSIFICATION: C50.3 M8500/31<br/> IN-SITU CARCINOMA: EQUIVOCAL.<br/> BREAST CANCER BIOMARKER STUDIES: <list> <item>PARAFFIN BLOCK NUMBER: A1.</item><item>ER INTERPRETATION: POSITIVE ESTROGEN RECEPTOR ACTIVITY (ALLRED SCORE = 8, Percentage stained tumor cells = 85%, 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><!-- Start Level 3 for Diagnostic Conclusion--> <entry> <!-- template 1.3.6.1.4.1.19376.1.8.1.3.6 'Problem Organizer' (2015-08-13T10:24:55) 1..* R--> </entry><entry> <!-- template 1.3.6.1.4.1.19376.1.3.10.4.5 'Update Information Organizer' (2017-11-14T15:22:14) 0..1 R --> </entry></section>
Item
DT
Kard
Konf
Beschreibung
Label
hl7:section
1 … 1
M
atpa...tion
@classCode
cs
1 … 1
F
DOCSECT
@moodCode
cs
1 … 1
F
EVN
Constraint
This section SHALL contain a code element populated with these attributes:
@code="22637-3"
@codeSystem="2.16.840.1.113883.6.1"
@displayName="Pathology report diagnosis"
This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.
The section SHALL contain as many Problem Organizer entry elements as there are problems or groups thereof investigated. Each entry provides machine-readable data.
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
M
atpa...tion
@root
uid
1 … 1
F
1.2.40.0.34.6.0.11.2.171
hl7:code
CE
1 … 1
M
atpa...tion
@displayName
st
0 … 1
@codeSystemName
st
0 … 1
F
LOINC
@code
CONF
1 … 1
F
22637-3
@codeSystem
1 … 1
F
2.16.840.1.113883.6.1 (LOINC)
hl7:title
ST
1 … 1
M
atpa...tion
CONF
Elementinhalt MUSS "Ergebnis" sein
hl7:text
SD.TEXT
1 … 1
M
atpa...tion
Beispiel
example for use case#1
<text> <paragraph> A1. "RIGHT BREAST FIVE CORES 8-9:00" (ULTRASOUND GUIDED NEEDLE CORE BIOPSY) </paragraph> 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> ICD-O-CLASSIFICATION: C50.3 M8500/31<br/> 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, Percentage stained tumor cells = 85%, 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>
Entwurf
