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Melanoma CDA.xml
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Melanoma CDA.xml
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<?xml version="1.0" encoding="utf-8"?>
<?xml-stylesheet type="text/xsl" href="./Content/xsl/CDA.xsl"?>
<!-- This is an example of creating a CDA document that represents a synoptic pathology report.
This docuement validates against the Lantana CDA validator https://www.lantanagroup.com/validator/Validator.
-->
<ClinicalDocument xsi:schemaLocation="urn:hl7-org:v3 NIST_C32_schema/C32_CDA.xsd" xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:sdtc="urn:hl7-org:sdtc">
<typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3" />
<!-- US General CDA Header Template -->
<templateId root="2.16.840.1.113883.10.20.22.1.1" />
<!-- We will use the CAP OID concatened with the eCC template ID as the id for this template. -->
<templateId root="2.16.840.1.113883.3.1434.121.100004300" />
<!-- Document unique identifier, presumably assigned by the system producing this document. -->
<id extension="99999" root="2.16.840.1.113883.19.5.99999.1" />
<!-- Codes for AP structured reports from IHE http://www.ihe.net/Technical_Framework/upload/IHE_PAT_Suppl_APSR_Rev1-1_TI_2011_03_31.pdf -->
<code code="11526-1" displayName="Pathology study" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" />
<!-- Title for this type of report, from eCC metadata. -->
<title>MELANOMA OF THE SKIN: Biopsy, Excision, Re-Excision</title>
<!-- Time this report was submitted. -->
<effectiveTime value="20130717182913" />
<!-- Boilerplate CDA headers that could be configured differently if necessary. -->
<confidentialityCode code="N" displayName="Normal" codeSystem="2.16.840.1.113883.5.25" />
<languageCode code="en-US" />
<!-- recordTarget is the patient. -->
<recordTarget>
<patientRole>
<id extension="456" root="2.16.840.1.113883.19.5.99999.2" />
<addr nullFlavor="NI" />
<telecom nullFlavor="NI" />
<patient>
<name use="L">
<given>Skip</given>
<given />
<family>Manam</family>
</name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male" />
<birthTime value="19680311" />
</patient>
</patientRole>
</recordTarget>
<!-- The author of the report is the pathologist. -->
<author>
<time value="20130717182913" />
<assignedAuthor>
<id extension="99999999" root="2.16.840.1.113883.4.6" />
<code code="200000000X" codeSystem="2.16.840.1.113883.6.101" displayName="Allopathic & Osteopathic Physicians" />
<addr nullFlavor="NI" />
<telecom nullFlavor="NI" />
<assignedPerson>
<name>
<given>John</given>
<family>Gonzalez</family>
</name>
</assignedPerson>
</assignedAuthor>
</author>
<!-- The custodian is the institution where the procedure was performed. -->
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id extension="99999999" root="2.16.840.1.113883.4.6" />
<name>General Hospital</name>
<telecom nullFlavor="NI" />
<addr nullFlavor="NI" />
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<!-- If the report is signed out, the legal authenticator is the physician. If the report is not signed out,
then the legalAuthenticator element should be absent. -->
<legalAuthenticator>
<time value="20130717182913" />
<signatureCode code="S" />
<assignedEntity>
<id extension="999999999" root="2.16.840.1.113883.4.6" />
<addr nullFlavor="NI" />
<telecom nullFlavor="NI" />
<assignedPerson>
<name>
<given>John</given>
<family>Gonzalez</family>
</name>
</assignedPerson>
</assignedEntity>
</legalAuthenticator>
<!-- We can associate this report with a particular Order ID using inFulfillmentOf/order/id/@root.
This should let the receiving system know what specimen this report documents. -->
<inFulfillmentOf>
<order>
<id root="sp56789" />
</order>
</inFulfillmentOf>
<!-- We are documenting a surgical pathology examination, which is represented as a serviceEvent with CPT-4 code. -->
<documentationOf typeCode="DOC">
<serviceEvent classCode="PCPR">
<code code="88302" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4" displayName="Level II - Surgical pathology, gross and microscopic examination Appendix, incidental, Fallopian tube, sterilization, Fingers/toes, amputation, traumatic, Foreskin, newborn, Hernia sac, any location, Hydrocele sac, Nerve, Skin, plastic repair, Sympathetic ganglion, Testis, castration, Vaginal mucosa, incidental, Vas deferens, sterilization" />
<effectiveTime>
<low value="20130717" />
<high value="20130717" />
</effectiveTime>
<performer typeCode="PPRF">
<functionCode code="PP" displayName="Primary Performer" codeSystem="2.16.840.1.113883.12.443" codeSystemName="Provider Role">
<originalText>Pathologist</originalText>
</functionCode>
<time>
<low value="20130717" />
<high value="20130717" />
</time>
<assignedEntity>
<id extension="999999999" root="2.16.840.1.113883.4.6" />
<code code="200000000X" codeSystem="2.16.840.1.113883.6.101" displayName="Allopathic & Osteopathic Physicians" />
<addr nullFlavor="NI" />
<telecom nullFlavor="NI" />
<assignedPerson>
<name>
<given>John</given>
<family>Gonzalez</family>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<!-- Now comes the structuredBody of the report. Each Section in the mTuitive/eCC will be represented by a section
following CDA syntax. The parent/child hierarchy is represented by nesting CDA sections within one another.
Whereever possible, CAP eCC CKEY identifiers are used as codes for both sections and values. In the future.
external mapping tables may be provided by CAP which could be pulled into this transform to produce LOINC and
SNOMED encodings. -->
<component>
<structuredBody>
<component>
<section>
<code code="11179.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Specimen Site" />
<title>Specimen Site</title>
<text />
<component>
<!-- This is the template for an individual Section. It will be coded if there is an eCC CKEY. It will always have a
title element for the section's label and a text element using CDA narrative block syntax to represent human-
readable content. Sections with units or lists with coded answers will also be represented with structured CDA
entry blocks. -->
<section>
<!-- Code identifying this section with its CAP eCC CKEY. Is CAP's HL7 OID a valid identifier for CKEYs as a code system? -->
<code code="11209.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Specimen Site" />
<!-- Title of the section. -->
<title>Specimen Site</title>
<!-- Human-readable representation using CDA narrative block syntax. -->
<text>
<list>
<item>Skin structure</item>
</list>
</text>
<!-- Structured CDA entry representing coded answers if available. -->
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="11343.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Skin structure" />
<text>Skin structure</text>
</observation>
</entry>
</section>
</component>
</section>
</component>
<component>
<section>
<code code="17465.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Specimen" />
<title>Specimen</title>
<component>
<section>
<code code="1881.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Procedure" />
<title>Procedure</title>
<text>
<list>
<item>Biopsy, punch</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="18250.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Biopsy, punch" />
<text>Biopsy, punch</text>
</observation>
</entry>
</section>
</component>
<component>
<section>
<code code="14477.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Primary Tumor Site" />
<title>Primary Tumor Site</title>
<text>
<list>
<item>Skin</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="20810.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Skin" />
<text>Skin</text>
</observation>
</entry>
<component>
<section>
<code code="20817.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Location on Skin" />
<title>Location on Skin</title>
<text>
<list>
<item>Skin of other and unspecified parts of face: USER ENTERED TEXT</item>
</list>
</text>
<entry>
<!-- Example of an observation with user-entered text in addition to a coded entry. -->
<observation classCode="OBS" moodCode="EVN">
<code code="20830.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Skin of other and unspecified parts of face" />
<text>Skin of other and unspecified parts of face: USER ENTERED TEXT</text>
</observation>
</entry>
</section>
</component>
<component>
<section>
<code code="20838.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Location on Penis" />
<title>Location on Penis</title>
<text />
</section>
</component>
<component>
<section>
<code code="20913.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Location on Vulva" />
<title>Location on Vulva</title>
<text />
</section>
</component>
</section>
</component>
<component>
<section>
<code code="18251.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Specimen Laterality" />
<title>Specimen Laterality</title>
<text>
<list>
<item>Right</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="18254.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Right" />
<text>Right</text>
</observation>
</entry>
</section>
</component>
<component>
<section>
<code code="14461.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Multiple Primary Sites (e.g., skin of neck and skin of shoulder)" />
<title>Multiple Primary Sites (e.g., skin of neck and skin of shoulder)</title>
<text />
</section>
</component>
<component>
<section>
<title>Multiple Primary Sites</title>
<text />
</section>
</component>
<component>
<section>
<code code="1904.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Macroscopic Satellite Nodule(s)" />
<title>Macroscopic Satellite Nodule(s)</title>
<text>
<list>
<item>Not identified: </item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="1905.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Not identified" />
<text>Not identified: </text>
</observation>
</entry>
</section>
</component>
<component>
<section>
<code code="1908.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Macroscopic Pigmentation" />
<title>Macroscopic Pigmentation</title>
<text>
<list>
<item>Not identified: </item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="1909.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Not identified" />
<text>Not identified: </text>
</observation>
</entry>
</section>
</component>
</section>
</component>
<component>
<section>
<code code="17466.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Tumor" />
<title>Tumor</title>
<component>
<section>
<code code="1915.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Histologic Type" />
<title>Histologic Type</title>
<text>
<list>
<item>Other (specify): USER ENTERED TEXT</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="1926.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Other (specify)" />
<text>Other (specify): USER ENTERED TEXT</text>
</observation>
</entry>
</section>
</component>
</section>
</component>
<component>
<section>
<code code="17467.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Extent" />
<title>Extent</title>
<component>
<section>
<code code="1899.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Tumor Size" />
<title>Tumor Size</title>
<component>
<section>
<code code="1901.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Greatest Dimension (cm)" />
<title>Greatest Dimension (cm)</title>
<text />
</section>
</component>
<component>
<section>
<code code="1902.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Additional Dimension (cm)" />
<title>Additional Dimension (cm)</title>
<text />
</section>
</component>
<component>
<section>
<code code="1903.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Additional Dimension (cm)" />
<title>Additional Dimension (cm)</title>
<text />
</section>
</component>
<component>
<section>
<title>Dimensions</title>
<text />
</section>
</component>
<component>
<section>
<code code="1900.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Size Cannot be Determined" />
<title>Reason Size Cannot be Determined</title>
<text>USER ENTERED TEXT</text>
</section>
</component>
</section>
</component>
<component>
<section>
<code code="1931.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Maximum Tumor Thickness" />
<title>Maximum Tumor Thickness</title>
<text>
<list>
<item>Can be determined</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code nullFlavor="UNK" />
<text>Can be determined</text>
</observation>
</entry>
</section>
</component>
<component>
<section>
<title>Maximum Tumor Thickness</title>
<component>
<section>
<code code="1932.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Indeterminate" />
<title>Indeterminate (Explain)</title>
<text />
</section>
</component>
</section>
</component>
<component>
<section>
<code code="18819.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Maximum Tumour Thickness (mm)" />
<title>Specify (mm)</title>
<text>2.1</text>
<entry>
<!-- Physican quantity observation using numbers and UCUM units. -->
<observation classCode="OBS" moodCode="EVN">
<code nullFlavor="UNK" />
<text>2.1 mm</text>
<value xsi:type="PQ" value="2.1" unit="mm" />
</observation>
</entry>
</section>
</component>
<component>
<section>
<code code="18820.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Maximum Tumour Thickness is at Least (mm)" />
<title>At least (mm)</title>
<text />
<component>
<section>
<code code="16992.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Explain" />
<title>Explain</title>
<text />
</section>
</component>
</section>
</component>
<component>
<section>
<code code="18257.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Anatomic Level" />
<title>Anatomic Level</title>
<text>
<list>
<item>IV (Melanoma invades reticular dermis)</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="18272.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="IV (Melanoma invades reticular dermis)" />
<text>IV (Melanoma invades reticular dermis)</text>
</observation>
</entry>
</section>
</component>
<component>
<section>
<code code="1928.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Ulceration" />
<title>Ulceration</title>
<text>
<list>
<item>Not identified: </item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="1930.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Not identified" />
<text>Not identified: </text>
</observation>
</entry>
</section>
</component>
</section>
</component>
<component>
<section>
<code code="1975.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Margins" />
<title>Margins</title>
<component>
<section>
<code code="1976.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Peripheral Margins" />
<title>Peripheral Margins</title>
<component>
<section>
<code code="1979.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Invasive" />
<title>Invasive</title>
<text>
<list>
<item>Involved by invasive melanoma</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="1983.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Involved by invasive melanoma" />
<text>Involved by invasive melanoma</text>
</observation>
</entry>
<component>
<section>
<code code="1981.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Distance of Invasive Melanoma From Closest Peripheral Margin (required for excisions only)" />
<title>Distance of Invasive Melanoma From Closest Peripheral Margin (required for excisions only)</title>
<text />
</section>
</component>
<component>
<section>
<code code="6539.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Distance From Closest Peripheral Margin (mm)" />
<title>Distance of Invasive Melanoma From Closest Peripheral Margin (mm)</title>
<text />
</section>
</component>
<component>
<section>
<code code="23224.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Distance From Closest Peripheral Margin Cannot be Determined" />
<title>Reason Distance of Invasive Melanoma From Closest Peripheral Margin Cannot be Assessed</title>
<text />
</section>
</component>
<component>
<section>
<title>Distance of Invasive Melanoma From Closest Peripheral Margin</title>
<text />
</section>
</component>
<component>
<section>
<code code="23809.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Location(s)" />
<title>Specify Location(s) (if possible)</title>
<text />
</section>
</component>
<component>
<section>
<code code="23812.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Location(s)" />
<title>Specify Location(s) (if possible)</title>
<text>
<list>
<item>Specify margin(s): USER ENTERED TEXT</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="23813.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Specify margin(s)" />
<text>Specify margin(s): USER ENTERED TEXT</text>
</observation>
</entry>
</section>
</component>
</section>
</component>
<component>
<section>
<code code="1985.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="In Situ" />
<title>In Situ</title>
<text>
<list>
<item>Not applicable - melanoma in situ not identified in specimen: </item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="21355.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Not applicable - melanoma in situ not identified in specimen" />
<text>Not applicable - melanoma in situ not identified in specimen: </text>
</observation>
</entry>
<component>
<section>
<code code="1987.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Distance of Melanoma In Situ From Closest Margin (required for excisions only)" />
<title>Distance of Melanoma In Situ From Closest Margin (required for excisions only)</title>
<text />
</section>
</component>
<component>
<section>
<code code="6551.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Distance From Closest Margin (mm)" />
<title>Distance of Melanoma in situ from Closest Margin (mm)</title>
<text />
</section>
</component>
<component>
<section>
<code code="23226.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Distance From Closest Margin Cannot be Assessed" />
<title>Reason Distance of Melanoma In Situ From Closest Margin Cannot be Assessed</title>
<text />
</section>
</component>
<component>
<section>
<title>Distance of Melanoma in situ from Closest Margin</title>
<text />
</section>
</component>
<component>
<section>
<code code="23815.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Location(s)" />
<title>Specify Location(s) (if possible)</title>
<text />
</section>
</component>
<component>
<section>
<code code="23818.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Location(s)" />
<title>Specify Location(s) (if possible)</title>
<text />
</section>
</component>
</section>
</component>
</section>
</component>
<component>
<section>
<code code="1991.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Deep Margin" />
<title>Deep Margin</title>
<text />
</section>
</component>
<component>
<section>
<code code="1994.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Deep Margin" />
<title>Deep Margin</title>
<text>
<list>
<item>Uninvolved by invasive melanoma</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="1995.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Uninvolved by invasive melanoma" />
<text>Uninvolved by invasive melanoma</text>
</observation>
</entry>
<component>
<section>
<code code="23833.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Distance of Invasive Melanoma From Margin (required for excisions only)" />
<title>Distance of Invasive Melanoma From Margin (required for excisions only)</title>
<text>
<list>
<item>Not applicable: </item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="23842.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Not applicable" />
<text>Not applicable: </text>
</observation>
</entry>
</section>
</component>
<component>
<section>
<code code="23834.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Distance of Invasive Melanoma from Margin (mm)" />
<title>Distance of Invasive Melanoma From Margin (mm)</title>
<text />
</section>
</component>
<component>
<section>
<code code="23835.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Distance of Invasive Melanoma from Margin Cannot be Assessed" />
<title>Reason Distance of Invasive Melanoma From Margin Cannot be Assessed</title>
<text />
</section>
</component>
<component>
<section>
<title>Distance of Invasive Melanoma From Margin</title>
<text>Not applicable</text>
</section>
</component>
<component>
<section>
<code code="23821.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Location(s)" />
<title>Specify Location(s), If Possible</title>
<text>
<list>
<item>Specify margin(s): USER ENTERED TEXT</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="23822.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Specify margin(s)" />
<text>Specify margin(s): USER ENTERED TEXT</text>
</observation>
</entry>
</section>
</component>
<component>
<section>
<code code="23824.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Location(s)" />
<title>Specify Location(s), If Possible</title>
<text />
</section>
</component>
</section>
</component>
</section>
</component>
<component>
<section>
<code code="17469.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Accessory Findings" />
<title>Accessory Findings</title>
<component>
<section>
<code code="2016.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Mitotic Rate" />
<title>Mitotic Rate</title>
<text>
<list>
<item>None identified: USER ENTERED TEXT</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="26549.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="None identified" />
<text>None identified: USER ENTERED TEXT</text>
</observation>
</entry>
<component>
<section>
<code code="26550.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Mitotic Rate" />
<title>Specify Number</title>
<text />
</section>
</component>
</section>
</component>
<component>
<section>
<title>Mitotic Rate</title>
<text>None identified: USER ENTERED TEXT</text>
</section>
</component>
<component>
<section>
<code code="18258.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Microsatellitosis" />
<title>Microsatellitosis</title>
<text>
<list>
<item>Not identified: </item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="18260.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Not identified" />
<text>Not identified: </text>
</observation>
</entry>
</section>
</component>
<component>
<section>
<code code="2000.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Lymph-Vascular Invasion" />
<title>Lymph-Vascular Invasion</title>
<text>
<list>
<item>Not identified: </item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="2001.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Not identified" />
<text>Not identified: </text>
</observation>
</entry>
</section>
</component>
<component>
<section>
<code code="2004.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Perineural Invasion" />
<title>Perineural Invasion</title>
<text>
<list>
<item>Not identified: </item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="2005.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Not identified" />
<text>Not identified: </text>
</observation>
</entry>
</section>
</component>
<component>
<section>
<code code="2008.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Tumor-Infiltrating Lymphocytes" />
<title>Tumor-Infiltrating Lymphocytes</title>
<text>
<list>
<item>Present, nonbrisk</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="2010.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Present, nonbrisk" />
<text>Present, nonbrisk</text>
</observation>
</entry>
</section>
</component>
<component>
<section>
<code code="2012.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Tumor Regression" />
<title>Tumor Regression</title>
<text>
<list>
<item>Not identified: </item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="2013.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Not identified" />
<text>Not identified: </text>
</observation>
</entry>
</section>
</component>
<component>
<section>
<code code="18265.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Growth Phase" />
<title>Growth Phase</title>
<text>
<list>
<item>Vertical</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="18276.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Vertical" />
<text>Vertical</text>
</observation>
</entry>
</section>
</component>
</section>
</component>
<component>
<section>
<code code="17471.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Lymph Nodes" />
<title>Lymph Nodes</title>
<text />
</section>
</component>
<component>
<section>
<code code="18817.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Lymph Nodes" />
<title>Lymph Nodes</title>
<text>
<list>
<item>Lymph nodes are not present in specimen</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="1933.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="?Lymph nodes are not present in specimen" />
<text>Lymph nodes are not present in specimen</text>
</observation>
</entry>
<component>
<section>
<code code="18280.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Total Number Examined (sentinel and nonsentinel)" />
<title>Total Number of Nodes Examined (sentinel and nonsentinel)</title>
<text />
</section>
</component>
<component>
<section>
<code code="18279.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Number of Sentinel Nodes Examined" />
<title>Number of Sentinel Nodes Examined</title>
<text />
</section>
</component>
<component>
<section>
<code code="6872.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Number Identified" />
<title>Number Identified</title>
<text />
</section>
</component>
<component>
<section>
<code code="6882.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Number Identified Cannot be Determined" />
<title>Reason Number Identified Cannot be Determined</title>
<text />
</section>
</component>
<component>
<section>
<code code="18281.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Number of Lymph Nodes With Metastases" />
<title>Number of Lymph Nodes With Metastases</title>
<text />
</section>
</component>
<component>
<section>
<code code="18281.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Number of Lymph Nodes With Metastases" />
<title>Number of Lymph Nodes With Metastases</title>
<text />
</section>
</component>
<component>
<section>
<code code="10031.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Lymph Nodes Involved" />
<title>Lymph Nodes Involved</title>
<text />
<component>
<section>
<code code="6861.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Number Containing Metastases Identified Macroscopically" />
<title>Number Containing Metastases Identified Macroscopically</title>
<text />
</section>
</component>
<component>
<section>
<code code="6862.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Reason Number Containing Metastases Macroscopically Cannot be Determined" />
<title>Reason Number Containing Metastases Macroscopically Cannot be Determined</title>
<text />
</section>
</component>
<component>
<section>
<code code="10061.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Number Containing Metastases Identified Microscopically" />
<title>Number Containing Metastases Identified Microscopically</title>
<text />
</section>
</component>
<component>
<section>
<code code="10067.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Reason Number Containing Metastases Microscopically Cannot be Determined" />
<title>Reason Number Containing Metastases Microscopically Cannot be Determined</title>
<text />
</section>
</component>
</section>
</component>
<component>
<section>
<title>Lymph Nodes Involved</title>
<text />
</section>
</component>
<component>
<section>
<code code="18283.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Extranodal Tumor Extension" />
<title>Extranodal Tumor Extension</title>
<text />
</section>
</component>
<component>
<section>
<code code="18286.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Size of Largest Metastatic Focus (mm) (for sentinel node)" />
<title>Size of Largest Metastatic Focus (mm) (for sentinel node)</title>
<text />
</section>
</component>
<component>
<section>
<code code="18287.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Location of Metastatic Tumor (for sentinel node)" />
<title>Location of Metastatic Tumor (for sentinel node)</title>
<text />
</section>
</component>
<component>
<section>
<code code="1965.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Matted Nodes" />
<title>Matted Nodes</title>
<text />
</section>
</component>
</section>
</component>
<component>
<section>
<code code="10026.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Lymph Nodes" />
<title>Lymph Nodes</title>
<text>
<list>
<item>No nodes submitted or found</item>
</list>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<code code="10027.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="No nodes submitted or found" />
<text>No nodes submitted or found</text>
</observation>
</entry>
</section>
</component>
<component>
<section>
<code code="1934.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Stage (pTNM)" />
<title>Stage (pTNM)</title>
<component>
<section>
<code code="16791.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="TNM Descriptors" />
<title>TNM Descriptors</title>
<text />
</section>
</component>
<component>
<section>
<code code="1935.100004300" codeSystem="2.16.840.1.113883.3.1434" codeSystemName="CAPECC" displayName="Primary Tumor (pT)" />
<title>Primary Tumor (pT)</title>
<text>
<list>