Cancer Pathology Data > Pathology Report Header

Entity

Data Element

Definition

Format

Valid Values

Purpose and Use

CCO Usage *

HL7 Field

Changes

Pathology Report Header

Type of Report

Code to indicate the type of the report. The report types will vary by facility depending on the functionality of the lab. The types of reports we require are:

A = Autopsy

B = Bone Marrow

C = Cytology

CG = Cytology (gynaecological)

FC = Flow Cytometry

H = Haematology

P = Surgical Pathology

Bx = Biopsy (for diagnostic biopsy specimens only)[1]

O = Other

U = Unknown

VARCHAR2(128)

Autopsy: 18743-5^Autopsy note^LN^A^Autopsy^L

Bone Marrow: 48807-2^Bone marrow aspiration report^LN^B^Autopsy^L

Cytology (non-gyn): 33716-2^Study Report: Cytology.non-gyn^LN^C^Cytology^L

Cytology (gynaecological):  33717-0^Study Report: Cytology.Cvx/Vag^LN ^C^Gyn Cytology^L

Flow Cytometry: 33719-6^Study Report FC, Immunophenotype^LN^F^ Flow Cytometry, Immunophenotype^L

Haematology: ^^^H^Hematology^L

Pathology (resection): 11529-5^Surgical Pathology Study PatReport^LN^P^Pathology^L

Diagnostic Biopsy (only): 11529-5^Surgical Pathology Study Report^LN^Bx^Biopsy^L

Other: ^^^O^Other^L

Unknown:  ^^^U^Unknown^L

Used to classify the various types of reports received from a facility.

R

OBR-4

Pathology Report Header

Surgeon Full Name

Full name of the surgeon/physician or other health care professional who performed the procedure. Surgeon name field should be filled in all cases regardless of the type of the professional performing the procedure.

VARCHAR2(128)

N/A

Required for researchers to request permission to contact patients.  Used for Surgical Pathology Indicator Reporting.

RE

OBR-10

Pathology Report Header

Surgeon CPSO Number 

CPSO number of the surgeon/ physician who performed the procedure. For health professionals (e.g. dentists, nurse practitioners, other non-MDs, etc.) who do not have a CPSO number, this field should be left blank.  

VARCHAR2(5)

College of Physician and Surgeons numbers preferred. See http://www.cpso.on.ca

Pathology Reporting Roadmap.

Required for researchers to request permission to contact patients. Used for Surgical Pathology Indicator Reporting.

RE

OBR-10

Pathology Report Header

Pathologist Full Name

Full name of the pathologist who created the report.

VARCHAR2(128)

N/A

Used to identify the pathologist who created the report, to follow-up if issues or question about a pathology report and for Pathology Data Quality and Surgical Pathology Indicator Reporting.

R

OBR-32

Pathology Report Header

Pathologist CPSO Number

ID of the pathologist who created the report.

VARCHAR2(5)

College of Physician and Surgeons numbers preferred. See http://www.cpso.on.ca

This will be a requirement in 2011, see Pathology Reporting Roadmap.

Used to identify the pathologist who created the report, to follow-up if issues or question about a pathology report and for Pathology Data Quality and Surgical Pathology Indicator Reporting.

R

OBR-32

Pathology Report Header

Specimen Collected Date

Date specimen was taken (surgery date), in text format.

VARCHAR2(16)

YYYY[MM[DD[HHMM[SS[.S[S[S[S]

Used to determine date of diagnosis, which is used in incidence statistics. Also used for Pathology Data Quality and Surgical Pathology Indicator Reporting.

R

OBR-7

Pathology Report

Report Sign Out Date

Date pathology report was signed off (completed), in text format.

VARCHAR2(16)

YYYYMMDD 

Can be used to determine time intervals and ensure the report has been finalized.

R

OBR-22

Pathology Report Header

Status of Report

F - Final

C - Change

When a report is initially sent, it will have a status of ‘F’. If the lab retransmits that report for any reason, (including supplements/addenda, or amendments,) the re-sent report should have a status of ‘C’.

VARCHAR2(1)

F = Final

C = Change

Used to determine if the report is the original, or if any change (correction or addendum) was made to the original.

R

OBR-25

Pathology Report Header

Transmitting Master Number

Facility code of the facility that transmits the report to CCO.

VARCHAR2(4)

4 digit numerical entry.

Used to Identify the transmitting facility.

R

MSH-4

Pathology Report Header

Current DX Accession Number

Specimen ID at the facility where the current diagnosis is made by a pathologist.

VARCHAR2(16)

Must contain only A-Z 0-9 / - or blank(s).

Used for case identification at the current diagnosis facility.

R

OBR-3

Pathology Report Header

Current DX Master Number

Facility code of the facility where the current diagnosis is made by a pathologist.

VARCHAR2(4)

4 digit numerical entry.

Used to Identify the current diagnosis facility and for facility based reporting statistics.

R

PID-3

Pathology Report Header

Current DX MRN

Patient chart number at the facility where the current diagnosis is made by a pathologist.

VARCHAR2(16)

Must contain only A-Z 0-9 / - or blank(s).

Used for patient identification at the current diagnosis facility.

R  

PID-3

Pathology Report Header

Referred-from Accession Number

Specimen ID at the facility where the original diagnosis is made by a pathologist.

VARCHAR2(16)

N/A

Used for case identification at the original diagnosis facility.

RE

OBR-2

Pathology Report Header

Referred-from Master Number

Facility code of the facility where the original diagnosis is made by a pathologist.

VARCHAR2( 4)

4 digit numerical entry

Used to Identify the original diagnosis facility and for facility based reporting statistics.

RE

PID-3

Pathology Report Header

Referred-from MRN

Patient chart number at the facility where the original diagnosis is made by a pathologist.

VARCHAR2(16)

Must contain only A-Z 0-9 / - or blank(s).

Used for patient identification at the original diagnosis facility.

RE

PID-3

Pathology Report Header

Collected Master Number

Facility code of the facility where the specimen was taken (i.e. Surgery Hospital).

VARCHAR2(4)

4 digit numerical entry.

Used to Identify the surgery facility.

RE

PID-3

Pathology Report Header

Collected MRN

Patient chart number at the facility where the  the specimen was taken (i.e. Surgery hospital).

VARCHAR2(16)

Must contain only A-Z 0-9 / - or blank(s).

Used for patient identification at surgery facility.

RE

PID-3

Pathology Report Header

Consult Indicator

This is to indicate whether the report is an external consult report in which case it should be marked with "Y" for yes. This field should remain empty if this is not an external consult report.

VARCHAR2(1)

Y or blank.

Used to determine if the report is a consult. If it is not a consult leave it blank.

RE

OBR-20

Pathology Report Header

Specimen Received Date/Time

For observations requiring a specimen, the specimen received date/time is the actual login time at the diagnostic service. This field must contain a value when the order is accompanied by a specimen, or when the observation required a specimen and the message is a report. For Cancer Reporting, generally surgery will collect the specimen; the date and time on the Pathology Study requisition form that accompanies the specimen is the timestamp filled in here.

VARCHAR2 (16)

Date

YYYY[MM[DD[HHMM[SS[.S[S[S[S]

Planning and Ontario Cancer Registry.

RE

New in 2019-20

To be populated by Hospitals currently capturing date/time specimen received at lab.