Specification - Extended

HL7 CDA® R2 IG: Reporting to Public Health Cancer Registries from Ambulatory Healthcare Providers, R1, DSTU Release 1.1 - US Realm

Document Description

extended per extended per TSC tracker 12458,14352, Jira TSC-14 and https://confluence.hl7.org/x/wpDGB

Existing Wording

This value SHALL contain exactly one [1..1] @code (CONF:1169-32464). Note: This @code attribute is used to document histologic type of tumor. If the histologic type isn’t known, the value of “8000” (with @displayName="Neoplasm") should be used when using code systems ICD-O-3, ICD-9-CM, ICD-10-CM and "86049000" (with @displayName="Neoplasm, malignant (primary)") when using SNOMED CT code system.

Proposed Wording

If the clinician does not know the specific histologic type of the cancer, then the value of “8000” (with @displayName="Neoplasm") should be used when using code systems ICD-O-3, ICD-9-CM, ICD-10-CM and "86049000" (with @displayName="Neoplasm, malignant (primary)") when using SNOMED CT code system. These two codes should only be used by the clinician to positively assert that the histologic type is unknown. It is not appropriate for the EHR system to set these codes as defaults when the clinician does not enter the histologic type information.