Difference between revisions of "Anatomic Pathology Structured Report"
| Line 9: | Line 9: | ||
This APSR 2.0 IHE content profile specifies a unique digital document template for an anatomic pathology structured report (APSR) to be shared or exchanged between pathology laboratories and other care providers and institutions. This content profile describes how to exchange a digital anatomic pathology report in a human-readable format, which may include images. In addition it also contains findings and observations in a machine-readable structured format to facilitate the integration of individual observations and interpretations into the database of a consumer system, which will enable the application of automated reasoning on this content. The digital document template uses the HL7 Clinical Document Architecture standard (CDA R2). | This APSR 2.0 IHE content profile specifies a unique digital document template for an anatomic pathology structured report (APSR) to be shared or exchanged between pathology laboratories and other care providers and institutions. This content profile describes how to exchange a digital anatomic pathology report in a human-readable format, which may include images. In addition it also contains findings and observations in a machine-readable structured format to facilitate the integration of individual observations and interpretations into the database of a consumer system, which will enable the application of automated reasoning on this content. The digital document template uses the HL7 Clinical Document Architecture standard (CDA R2). | ||
| − | Anatomic pathology structured reports document the findings on specimens removed from patients for diagnostic or therapeutic reasons covering all aspects of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as cytopathology. This information can be used for patient care, clinical research and epidemiology | + | Anatomic pathology structured reports document the findings on specimens removed from patients for diagnostic or therapeutic reasons covering all aspects of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as cytopathology. This information can be used for patient care, clinical research and epidemiology. |
The document template includes a header conveying the contextual metadata of the report, and a structured body organized in sections. Each section contains a narrative content for the human reader and may also contain a number of entries carrying the corresponding structured data intended to be integrated in the database of consuming applications. | The document template includes a header conveying the contextual metadata of the report, and a structured body organized in sections. Each section contains a narrative content for the human reader and may also contain a number of entries carrying the corresponding structured data intended to be integrated in the database of consuming applications. | ||
| − | + | <center>[[Image:apsr2layout.jpg]]</center> | |
''<See [[Help:Contents#Tips_.26_Tricks| Help - Tips and Tricks]] for details on inserting an image/graphic.>'' | ''<See [[Help:Contents#Tips_.26_Tricks| Help - Tips and Tricks]] for details on inserting an image/graphic.>'' | ||
| Line 19: | Line 19: | ||
==Benefits== | ==Benefits== | ||
| − | + | Standardizing and computerizing anatomic pathology reports is necessary to improve the quality of reporting and to facilitate the exchange and reuse of the content of these reports. | |
==Details== | ==Details== | ||
Revision as of 00:40, 17 July 2018
| This profile is part of the Pathology and Laboratory Medicine (PaLM) domain, which merged the former AP and LAB domains since 2016, January 4th. |
Page in construction
Summary
This APSR 2.0 IHE content profile specifies a unique digital document template for an anatomic pathology structured report (APSR) to be shared or exchanged between pathology laboratories and other care providers and institutions. This content profile describes how to exchange a digital anatomic pathology report in a human-readable format, which may include images. In addition it also contains findings and observations in a machine-readable structured format to facilitate the integration of individual observations and interpretations into the database of a consumer system, which will enable the application of automated reasoning on this content. The digital document template uses the HL7 Clinical Document Architecture standard (CDA R2).
Anatomic pathology structured reports document the findings on specimens removed from patients for diagnostic or therapeutic reasons covering all aspects of anatomic pathology (cancers, benign neoplasms as well as non-neoplastic conditions) as well as cytopathology. This information can be used for patient care, clinical research and epidemiology.
The document template includes a header conveying the contextual metadata of the report, and a structured body organized in sections. Each section contains a narrative content for the human reader and may also contain a number of entries carrying the corresponding structured data intended to be integrated in the database of consuming applications.
<See Help - Tips and Tricks for details on inserting an image/graphic.>
Benefits
Standardizing and computerizing anatomic pathology reports is necessary to improve the quality of reporting and to facilitate the exchange and reuse of the content of these reports.
Details
<A few paragraphs, if appropriate, providing more details (mostly in user-speak, not tech-speak) on what the profile does and how it works.>
<If the user might be familiar with the mechanisms used by the profile, you can mention them here. E.g. Evidence Documents is based on DICOM Structured Report (SR) Templates.>
<If the user might have an appreciation for the problems addressed in the profile, you can mention them here, but keep it short. E.g. Mapping HL7 Order fields to DICOM Modality Worklist attributes can be inconsistent in the marketplace, so Scheduled Workflow provides vendors with more detailed instructions.>
Systems Affected
<List (in user terms) the types of systems they might expect to have implemented actors from this profile, e.g. RIS, PACS, HIS, CAD Workstation, etc. and for each, how it would participate.>
- PACS systems may store, manage, and/or display Evidence Documents.
- Display systems may query, retrieve and display Evidence Documents.
- Reporting workstations may retrieve, process and include details from Evidence Documents in reports
Actors & Transactions:
<Insert an actor-transaction diagram, and or list of Content Definitions>
Specification
Profile Status: Final Text <Replace "Final Text" with "Trial Implementation" or "Public Comment" as appropriate.>
Documents:
<Provide direct links to the specific volumes or supplements, and list the volume sections relevant to this profile. This is a simple inventory of official normative and informative text. If you would like to provide a reading guide or walkthrough of what is in each of the different sections for implementers or users, do that in the Profile FAQ or the Profile Implementation Page linked below. If the profile uses transactions from multiple Tech. Frameworks, repeat the structure below.>
IHE Radiology Technical Framework:
Underlying Standards:
<list all the standards on which the profile is based; if possible with links to sources>
See Also
<The following sections can be left out if there is nothing to point to. This is just to show where such information can go.>
This page is based on the Profile Template