hl7:act
|
|
1 … 1 |
M |
|
(Spe MDL) |
|
|
@classCode
|
|
1 … 1 |
F |
ACT |
@moodCode
|
|
1 … 1 |
F |
EVN |
hl7:templateId
|
II |
1 … 1 |
|
|
(Spe MDL) |
@root
|
|
1 … 1 |
F |
2.16.840.1.113883.2.4.3.36.10.333 |
hl7:code
|
CE |
1 … 1 |
M |
|
(Spe MDL) |
@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 |
|
(Spe MDL) |
@typeCode
|
|
1 … 1 |
F |
SPC |
hl7:specimenRole
|
|
1 … 1 |
M |
|
(Spe MDL) |
@classCode
|
|
1 … 1 |
F |
SPEC |
hl7:id
|
II |
1 … 1 |
|
monster identificatie (uniek potje nummer), indien geen monster verzameld wordt @nullFlavor="NI"
aangegeven
|
(Spe MDL) |
hl7:specimenPlayingEntity
|
|
0 … 1 |
|
|
(Spe MDL) |
|
|
@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
|
(Spe MDL) |
|
|
|
CONF |
|
hl7:quantity
|
|
0 … 1 |
|
|
(Spe MDL) |
lab:asSpecimenInContainer
|
|
0 … 1 |
|
|
(Spe MDL) |
@classCode
|
|
1 … 1 |
F |
CONT |
lab:container
|
|
1 … 1 |
M |
|
(Spe MDL) |
@classCode
|
|
1 … 1 |
F |
CONT |
@determinerCode
|
|
1 … 1 |
F |
INSTANCE |
lab:id
|
|
1 … 1 |
R |
locaal potje nummer, uniek is alleen de monster identificatie |
(Spe MDL) |
|
|
@extension
|
|
1 … 1 |
R |
|
@nullFlavor
|
|
1 … 1 |
F |
UNC |
|
Voorbeeld |
<lab:id extension="1" nullFlavor="UNC"/> |
lab:productOf
|
|
0 … * |
|
|
(Spe MDL) |
@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 … * |
|
|
(Spe MDL) |
@classCode
|
|
1 … 1 |
F |
SPECCOLLECT |
@moodCode
|
|
1 … 1 |
F |
EVN |
lab:code
|
CD |
0 … 1 |
|
Wijze van verkrijgen |
(Spe MDL) |
|
|
|
CONF |
|
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900110 Manierverwijdering (DYNAMISCH)
|
lab:qualifier
|
|
|
|
|
(Spe MDL) |
waar [lab:name/@code='84203001'] |
|
lab:name
|
CE |
1 … 1 |
M |
|
(Spe MDL) |
@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 |
|
(Spe MDL) |
|
|
|
CONF |
|
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900111 Volledigheidverwijdering (DYNAMISCH)
|
lab:qualifier
|
|
|
|
|
(Spe MDL) |
waar [lab:name/@code='272142003'] |
|
lab:name
|
CE |
1 … 1 |
M |
|
(Spe MDL) |
@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 |
|
(Spe MDL) |
|
|
|
CONF |
|
lab:targetSiteCode
|
CE |
0 … 1 |
|
locatie/oriëntatie |
(Spe MDL) |
|
|
|
CONF |
|
lab:methodCode
|
CE |
0 … 1 |
|
Manier van verwijderen |
(Spe MDL) |
|
CONF |
|
lab:originalText
|
ST |
0 … 1 |
C |
Verplicht indien bij Manier van verwijderen #145080 lab:methodCode voor overige is
gekozen
|
(Spe MDL) |
|
|
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)
|
(Spe MDL) |
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)
|
(Spe MDL) |
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)
|
(Spe MDL) |
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)
|
(Spe MDL) |
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)
|
(Spe MDL) |
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)
|
(Spe MDL) |
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)
|
(Spe MDL) |
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)
|
(Spe MDL) |
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)
|
(Spe MDL) |
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)
|
(Spe MDL) |
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)
|
(Spe MDL) |
waar [lab:observationEvent/lab:code/@code='14792009'] |
|
@typeCode
|
|
1 … 1 |
F |
SBJ |