hl7:act
|
|
1 … 1 |
M |
|
(SpeMDL) |
|
|
@classCode
|
|
1 … 1 |
F |
ACT |
@moodCode
|
|
1 … 1 |
F |
EVN |
hl7:templateId
|
II |
1 … 1 |
|
|
(SpeMDL) |
@root
|
|
1 … 1 |
F |
2.16.840.1.113883.2.4.3.36.10.333 |
hl7:code
|
CE |
1 … 1 |
M |
|
(SpeMDL) |
@code
|
CONF |
1 … 1 |
F |
X-LAB-SPMSCT |
@codeSystem
|
1 … 1 |
F |
2.16.840.1.113883.6.1 (LOINC) |
hl7:specimen
|
|
1 … 1 |
M |
|
(SpeMDL) |
@typeCode
|
|
1 … 1 |
F |
SPC |
hl7:specimenRole
|
|
1 … 1 |
M |
|
(SpeMDL) |
@classCode
|
|
1 … 1 |
F |
SPEC |
hl7:id
|
II |
1 … 1 |
|
monster identificatie (uniek potje nummer), indien geen monster verzameld wordt @nullFlavor="NI"
aangegeven
|
(SpeMDL) |
hl7:specimenPlayingEntity
|
|
0 … 1 |
|
|
(SpeMDL) |
|
|
@classCode
|
|
1 … 1 |
F |
ENT |
@determinerCode
|
|
1 … 1 |
F |
INSTANCE |
hl7:code
|
CE |
0 … 1 |
|
Materiaal van het monster is (op dit moment) of polyp of biopt. In het geval van een gefragmenteerd poliep is hier poliepectomie aan te geven en
bij volledigheid verwijdering (template 2.16.840.1.113883.2.4.3.36.10.900111) "incompleet" Afhankelijk hiervan kunnen observaties op het monster worden ingevuld:
- Indien polyp: Diameterpoliep 1..1, Morfologie 1..1, Klinischediagnosepoliep 1..*,
Poliepvastgelegd 1..1
- Indien biopt (bij verdenking carcinoom): Carcinoom 1..1, Stenosis 0..1, Circumferencemeasure
0..1, Linearextent 0..1, Carcinomapassable 0..1
|
(SpeMDL) |
|
|
|
CONF |
|
hl7:quantity
|
|
0 … 1 |
|
|
(SpeMDL) |
lab:asSpecimenInContainer
|
|
0 … 1 |
|
|
(SpeMDL) |
@classCode
|
|
1 … 1 |
F |
CONT |
lab:container
|
|
1 … 1 |
M |
|
(SpeMDL) |
@classCode
|
|
1 … 1 |
F |
CONT |
@determinerCode
|
|
1 … 1 |
F |
INSTANCE |
lab:id
|
|
1 … 1 |
R |
locaal potje nummer, uniek is alleen de monster identificatie |
(SpeMDL) |
|
|
@extension
|
|
1 … 1 |
R |
|
@nullFlavor
|
|
1 … 1 |
F |
UNC |
|
Voorbeeld |
<lab:id extension="1" nullFlavor="UNC"/> |
lab:productOf
|
|
0 … * |
|
|
(SpeMDL) |
@typeCode
|
|
1 … 1 |
F |
PRD |
|
Voorbeeld |
<lab:productOf typeCode="PRD"> <lab:specimenCollectionProcess classCode="SPECCOLLECT" moodCode="EVN"> <lab:code code="82035006" codeSystem="2.16.840.1.113883.6.96" displayName="Resection of polyp"/> <lab:targetSiteCode code="362166007" codeSystem="2.16.840.1.113883.6.96" displayName="Sigmoid"/> </lab:specimenCollectionProcess></lab:productOf> |
lab:specimenCollectionProcess
|
|
0 … * |
|
|
(SpeMDL) |
@classCode
|
|
1 … 1 |
F |
SPECCOLLECT |
@moodCode
|
|
1 … 1 |
F |
EVN |
lab:code
|
CD |
0 … 1 |
|
Wijze van verkrijgen |
(SpeMDL) |
|
|
|
CONF |
|
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900110 Manierverwijdering (DYNAMISCH)
|
lab:qualifier
|
|
|
|
|
(SpeMDL) |
|
|
|
|
|
|
waar [lab:name/@code='84203001'] |
|
|
lab:name
|
CE |
1 … 1 |
M |
|
(SpeMDL) |
@code
|
CONF |
1 … 1 |
F |
84203001 |
@codeSystem
|
1 … 1 |
F |
2.16.840.1.113883.6.96 (Snomed CT) |
lab:value
|
CE |
0 … 1 |
R |
|
(SpeMDL) |
|
|
|
CONF |
|
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900111 Volledigheidverwijdering (DYNAMISCH)
|
lab:qualifier
|
|
|
|
|
(SpeMDL) |
|
|
|
|
|
|
waar [lab:name/@code='272142003'] |
|
|
lab:name
|
CE |
1 … 1 |
M |
|
(SpeMDL) |
@code
|
CONF |
1 … 1 |
F |
272142003 |
@codeSystem
|
1 … 1 |
F |
2.16.840.1.113883.6.96 (Snomed CT) |
lab:value
|
CE |
0 … 1 |
R |
|
(SpeMDL) |
|
|
|
CONF |
|
lab:targetSiteCode
|
CE |
0 … 1 |
|
locatie/oriëntatie |
(SpeMDL) |
|
|
|
CONF |
|
lab:methodCode
|
CE |
0 … 1 |
|
Manier van verwijderen |
(SpeMDL) |
|
CONF |
|
lab:originalText
|
ST |
0 … 1 |
C |
Verplicht indien bij Manier van verwijderen #145080 lab:methodCode voor overige is
gekozen
|
(SpeMDL) |
|
|
lab:subjectOf
|
|
0 … 1 |
C |
Bevat 2.16.840.1.113883.2.4.3.36.10.348 Distance from anal verge (laesie) (2014‑02‑09)
|
(SpeMDL) |
|
|
|
waar [lab:observationEvent/lab:code/@code='C145061'] |
|
|
@typeCode
|
|
1 … 1 |
F |
SBJ |
lab:subjectOf
|
|
0 … 1 |
|
Bevat 2.16.840.1.113883.2.4.3.36.10.900102 Diameter poliep (2012‑04‑10)
|
(SpeMDL) |
|
|
|
waar [lab:observationEvent/lab:code/@code='384627007'] |
|
|
@typeCode
|
|
1 … 1 |
F |
SBJ |
lab:subjectOf
|
|
0 … 1 |
|
Bevat 2.16.840.1.113883.2.4.3.36.10.900109 Morfologie (DYNAMISCH)
|
(SpeMDL) |
|
|
|
waar [lab:observationEvent/lab:code/@code='41329004'] |
|
|
@typeCode
|
|
1 … 1 |
F |
SBJ |
lab:subjectOf
|
|
1 … 1 |
R |
Bevat 2.16.840.1.113883.2.4.3.36.10.900106 Klinische diagnose poliep (DYNAMISCH)
|
(SpeMDL) |
|
|
|
waar [lab:observationEvent/lab:code/@code='DX'] |
|
|
@typeCode
|
|
1 … 1 |
F |
SBJ |
|
Schematron assert |
role |
error
|
|
|
test |
(not(hl7:specimenPlayingEntity) or hl7:specimenPlayingEntity/hl7:code/@code!='309226005'
or lab:subjectOf[lab:observationEvent/lab:code/@code='384627007'])
|
|
|
Melding |
If type of specimen = polpy, Diameterpoliep SHALL be present |
|
|
Schematron assert |
role |
error
|
|
|
test |
(not(hl7:specimenPlayingEntity) or hl7:specimenPlayingEntity/hl7:code/@code!='309226005'
or lab:subjectOf[lab:observationEvent/lab:code/@code='41329004'])
|
|
|
Melding |
If type of specimen = polpy, Morfologie SHALL be present |
|
|
Schematron assert |
role |
error
|
|
|
test |
(not(hl7:specimenPlayingEntity) or hl7:specimenPlayingEntity/hl7:code/@code!='309226005'
or lab:subjectOf[lab:observationEvent/lab:code/@code='DX'])
|
|
|
Melding |
If type of specimen = polpy, Klinischediagnosepoliep SHALL be present |
|
lab:subjectOf
|
|
0 … 1 |
|
Bevat 2.16.840.1.113883.2.4.3.36.10.339 Carcinoom (DYNAMISCH)
|
(SpeMDL) |
|
|
|
waar [lab:observationEvent/lab:code/@code='269533000'] |
|
|
@typeCode
|
|
1 … 1 |
F |
SBJ |
lab:subjectOf
|
|
0 … 1 |
|
Bevat 2.16.840.1.113883.2.4.3.36.10.424 Stenosis of colon (DYNAMISCH)
|
(SpeMDL) |
|
|
|
waar [lab:observationEvent/lab:code/@code='19132000'] |
|
|
@typeCode
|
|
1 … 1 |
F |
SBJ |
lab:subjectOf
|
|
0 … 1 |
|
Bevat 2.16.840.1.113883.2.4.3.36.10.425 Circumference measure (DYNAMISCH)
|
(SpeMDL) |
|
|
|
waar [lab:observationEvent/lab:code/@code='248365001'] |
|
|
@typeCode
|
|
1 … 1 |
F |
SBJ |
lab:subjectOf
|
|
0 … 1 |
|
Bevat 2.16.840.1.113883.2.4.3.36.10.426 Linear extent of involvement of carcinoma (DYNAMISCH)
|
(SpeMDL) |
|
|
|
waar [lab:observationEvent/lab:code/@code='385300008'] |
|
|
@typeCode
|
|
1 … 1 |
F |
SBJ |
lab:subjectOf
|
|
0 … 1 |
|
Bevat 2.16.840.1.113883.2.4.3.36.10.900120 Distance of tumor from anal verge (2015‑02‑14)
|
(SpeMDL) |
|
|
|
waar [lab:observationEvent/lab:code/@code='371490004'] |
|
|
@typeCode
|
|
1 … 1 |
F |
SBJ |
lab:subjectOf
|
|
0 … 1 |
|
Bevat 2.16.840.1.113883.2.4.3.36.10.427 Carcinoma passable (DYNAMISCH)
|
(SpeMDL) |
|
|
|
waar [lab:observationEvent/lab:code/@code='C145140'] |
|
|
@typeCode
|
|
1 … 1 |
F |
SBJ |
lab:subjectOf
|
|
0 … 1 |
|
Bevat 2.16.840.1.113883.2.4.3.36.10.900118 Tattooing (DYNAMISCH)
|
(SpeMDL) |
|
|
|
waar [lab:observationEvent/lab:code/@code='14792009'] |
|
|
@typeCode
|
|
1 … 1 |
F |
SBJ |