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<table class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="border:1px solid #C0C0C0; width: 107pt;" align="left"><strong>Template </strong></th><td align="left" style="background-color: #F6F3EE">Pflegediagnose Entry<i> / PflegediagnoseEntry</i></td></tr><tr><th align="left">Id</th><td align="left" style="background-color: #F6F3EE">1.2.276.0.76.10.4001</td></tr><tr><th align="left">Klassifikation</th><td align="left" style="background-color: #F6F3EE">CDA entry level template</td></tr><tr><th align="left">Kontext</th><td align="left" style="background-color: #F6F3EE">Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4001</td></tr><tr><th align="left"> Version </th><td align="left" style="background-color: #F6F3EE"> gültig ab 2013‑01‑23 Status In Entwicklung</td></tr><tr valign="top"><th align="left">Offen/Geschlossen</th><td style="background-color: #F6F3EE">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr><td colspan="2" class="tabtab"><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="6" style="background: transparent;"><tr><th align="left" width="1%">Item</th><th align="left" width="1%">DT</th><th align="left" width="1%">Card</th><th align="left" width="1%">Conf</th><th align="left">Desc</th><th align="left" width="1%">Label</th></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:act<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong></strong></td><td style="vertical-align: top;"><span style="color: black;"><strong></strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>classCode<br></strong></tt></td></tr></table></td><td></td><td>1&nbsp;..&nbsp;1</td><td>F</td><td colspan="2">ACT</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>moodCode<br></strong></tt></td></tr></table></td><td></td><td>1&nbsp;..&nbsp;1</td><td>F</td><td colspan="2">EVN</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:templateId<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>II</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1&nbsp;..&nbsp;1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>root<br></strong></tt></td></tr></table></td><td></td><td>1&nbsp;..&nbsp;1</td><td>F</td><td colspan="2">1.2.276.0.76.10.4001</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:statusCode<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>CS</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1&nbsp;..&nbsp;1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>code<br></strong></tt></td></tr></table></td><td></td><td>1&nbsp;..&nbsp;1</td><td>F</td><td colspan="2">active</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:entryRelationship<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong></strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1&nbsp;..&nbsp;1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:observation<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong></strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1&nbsp;..&nbsp;1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:templateId<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong></strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1&nbsp;..&nbsp;1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>root<br></strong></tt></td></tr></table></td><td></td><td>1&nbsp;..&nbsp;1</td><td>F</td><td colspan="2">2.999.888.777.22.77.10.19</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:code<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>CE</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1&nbsp;..&nbsp;1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>code<br></strong></tt></td></tr></table></td><td></td><td>1&nbsp;..&nbsp;1</td><td>F</td><td colspan="2">CAREDX</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>codeSystem<br></strong></tt></td></tr></table></td><td></td><td>1&nbsp;..&nbsp;1</td><td>F</td><td colspan="2">1.2.276.0.76.5.342</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:value<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>CD</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1&nbsp;..&nbsp;1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td style="background-color: white"></td><td class="conf" valign="top">CONF </td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr valign="top"><td>@codeSystem muss "2.16.840.1.113883.6.97" sein</td></tr><tr valign="top"><td>oder</td></tr><tr valign="top"><td>@codeSystem muss "2.16.840.1.113883.6.204" sein</td></tr><tr valign="top"><td>oder</td></tr><tr valign="top"><td>@codeSystem muss "2.16.840.1.113883.6.254" sein</td></tr><tr valign="top"><td>oder</td></tr><tr valign="top"><td>@codeSystem muss "2.16.840.1.113883.6.236" sein</td></tr><tr valign="top"><td>oder</td></tr><tr valign="top"><td>@codeSystem muss "1.2.276.0.76.3.1.125.1" sein</td></tr><tr valign="top"><td>oder</td></tr><tr valign="top"><td>@codeSystem muss "1.2.276.0.76.5.407" sein</td></tr></table></td></tr></table></td></tr></table>
+
<table class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="border:1px solid #C0C0C0; width: 107pt;" align="left"><strong>Template </strong></th><td align="left" style="background-color: #F6F3EE">Pflegediagnose Entry<i> / PflegediagnoseEntry</i></td></tr><tr><th align="left">Id</th><td align="left" style="background-color: #F6F3EE">1.2.276.0.76.10.4001</td></tr><tr><th align="left">Klassifikation</th><td align="left" style="background-color: #F6F3EE">CDA entry level template</td></tr><tr><th align="left">Kontext</th><td align="left" style="background-color: #F6F3EE">Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4001</td></tr><tr><th align="left"> Version </th><td align="left" style="background-color: #F6F3EE"> gültig ab 2013‑01‑23 Status In Entwicklung</td></tr><tr valign="top"><th align="left">Offen/Geschlossen</th><td style="background-color: #F6F3EE">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr valign="top"><th align="left">Beschreibung</th><td>                <span class="xforms-group" id="xf-242">                    <span class="fr-accordion-lnf xforms-group" id="xf-303$fr-accordion-group">                        <span class="xforms-group" id="xf-303$xf-794">Mit  diesem entry template werden maschinenlesbare pflegerische Zustandsbeschreibungen  transportiert.                  Diese Zustandsbeschreibungen können in Form von  Pflegediagnosen oder Pflegeproblemen vorliegen.                  Gemein ist beiden Formen, dass Pflege aufgrund dieser  Zustände aktiv wird. Das bedeutet, dass eine Pflegediagnose zumeist eine  Pflegeintervention nach sich zieht. Folgende internationale Klassifikationen stehen (kostenpflichtig) zur Verfügung: International Classification of Nursing Pracitce (ICNP), NANDA-I Diagnoses, International Classification of Functioning, Disability and Health (ICF), Clinical Care Classification (CCC). Auf nationaler Ebene können neben den Übersetzungen der internationalen Klassifikationen folgende Terminologien (ggf. kostenplfichtig) genutzt werden: apenio bzw. European Nursing Care Pathways (ENP). <br clear="none">                        </span>                    </span>                </span>            </td></tr><tr class="explabel" valign="top"><td>Beispiel</td><td class="explabelblue"><tt><div><span class="ppsign">&lt;</span><span class="ppnamespace"></span><span class="ppelement">act</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">ACT</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><div></div><div>&nbsp;&nbsp;<span class="ppsign">&lt;</span><span class="ppnamespace"></span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.4001</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><div></div></div><div>&nbsp;&nbsp;<span class="ppsign">&lt;</span><span class="ppnamespace"></span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">active</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><div></div></div><div>&nbsp;&nbsp;<span class="ppsign">&lt;</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span><div></div><div>&nbsp;&nbsp;&nbsp;&nbsp;<span class="ppsign">&lt;</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span><div></div><div>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span class="ppsign">&lt;</span><span class="ppnamespace"></span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.999.888.777.22.77.10.19</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><div></div></div><div>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span class="ppsign">&lt;</span><span class="ppnamespace"></span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">CAREDX</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.342</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><div></div></div><div>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span class="ppsign">&lt;</span><span class="ppnamespace"></span><span class="ppelement">value</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">A01.5</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.236</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Beeinträchtigung der körperlichen Mobilität</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">Clinical Care Classification</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><div></div></div>&nbsp;&nbsp;&nbsp;&nbsp;<span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></div>&nbsp;&nbsp;<span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></div><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">act</span><span class="ppsign">&gt;</span></div></tt></td></tr><tr class="explabel" valign="top"><td>Beispiel</td><td class="explabelblue"><tt><div><span class="ppsign">&lt;</span><span class="ppnamespace"></span><span class="ppelement">act</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">ACT</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><div></div><div>&nbsp;&nbsp;<span class="ppsign">&lt;</span><span class="ppnamespace"></span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.4001</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><div></div></div><div>&nbsp;&nbsp;<span class="ppsign">&lt;</span><span class="ppnamespace"></span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">active</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><div></div></div><div>&nbsp;&nbsp;<span class="ppsign">&lt;</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span><div></div><div>&nbsp;&nbsp;&nbsp;&nbsp;<span class="ppsign">&lt;</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span><div></div><div>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span class="ppsign">&lt;</span><span class="ppnamespace"></span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.999.888.777.22.77.10.19</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><div></div></div><div>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span class="ppsign">&lt;</span><span class="ppnamespace"></span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">CAREDX</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.342</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><div></div></div><div>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<span class="ppsign">&lt;</span><span class="ppnamespace"></span><span class="ppelement">value</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">10001219</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.97</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Impaired Mobility</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">Intermational Classification of Nursing Practice</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><div></div></div>&nbsp;&nbsp;&nbsp;&nbsp;<span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></div>&nbsp;&nbsp;<span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></div><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">act</span><span class="ppsign">&gt;</span></div></tt></td></tr><tr><td colspan="2" class="tabtab"><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="6" style="background: transparent;"><tr><th align="left" width="1%">Item</th><th align="left" width="1%">DT</th><th align="left" width="1%">Card</th><th align="left" width="1%">Conf</th><th align="left">Desc</th><th align="left" width="1%">Label</th></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:act<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong></strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>0&nbsp;..&nbsp;*</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>classCode<br></strong></tt></td></tr></table></td><td></td><td>1&nbsp;..&nbsp;1</td><td>F</td><td colspan="2">ACT</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>moodCode<br></strong></tt></td></tr></table></td><td></td><td>1&nbsp;..&nbsp;1</td><td>F</td><td colspan="2">EVN</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:templateId<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>II</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1&nbsp;..&nbsp;1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>root<br></strong></tt></td></tr></table></td><td></td><td>1&nbsp;..&nbsp;1</td><td>F</td><td colspan="2">1.2.276.0.76.10.4001</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:statusCode<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>CS</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1&nbsp;..&nbsp;1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>code<br></strong></tt></td></tr></table></td><td></td><td>1&nbsp;..&nbsp;1</td><td>F</td><td colspan="2">active</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:entryRelationship<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong></strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1&nbsp;..&nbsp;1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:observation<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong></strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1&nbsp;..&nbsp;1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:templateId<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong></strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1&nbsp;..&nbsp;1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>root<br></strong></tt></td></tr></table></td><td></td><td>1&nbsp;..&nbsp;1</td><td>F</td><td colspan="2">2.999.888.777.22.77.10.19</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:code<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>CE</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1&nbsp;..&nbsp;1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>code<br></strong></tt></td></tr></table></td><td></td><td>1&nbsp;..&nbsp;1</td><td>F</td><td colspan="2">CAREDX</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>codeSystem<br></strong></tt></td></tr></table></td><td></td><td>1&nbsp;..&nbsp;1</td><td>F</td><td colspan="2">1.2.276.0.76.5.342</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:value<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>CD</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1&nbsp;..&nbsp;1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td style="background-color: white"></td><td class="conf" valign="top">CONF </td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr valign="top"><td>@codeSystem muss "2.16.840.1.113883.6.97" sein</td></tr><tr valign="top"><td>oder</td></tr><tr valign="top"><td>@codeSystem muss "2.16.840.1.113883.6.204" sein</td></tr><tr valign="top"><td>oder</td></tr><tr valign="top"><td>@codeSystem muss "2.16.840.1.113883.6.254" sein</td></tr><tr valign="top"><td>oder</td></tr><tr valign="top"><td>@codeSystem muss "2.16.840.1.113883.6.236" sein</td></tr><tr valign="top"><td>oder</td></tr><tr valign="top"><td>@codeSystem muss "1.2.276.0.76.3.1.125.1" sein</td></tr><tr valign="top"><td>oder</td></tr><tr valign="top"><td>@codeSystem muss "1.2.276.0.76.5.407" sein</td></tr></table></td></tr></table></td></tr></table>

Version vom 25. August 2014, 07:36 Uhr

Template Pflegediagnose Entry / PflegediagnoseEntry
Id1.2.276.0.76.10.4001
KlassifikationCDA entry level template
KontextElternknoten des Template-Element mit Id 1.2.276.0.76.10.4001
Version gültig ab 2013‑01‑23 Status In Entwicklung
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Beschreibung Mit diesem entry template werden maschinenlesbare pflegerische Zustandsbeschreibungen transportiert. Diese Zustandsbeschreibungen können in Form von Pflegediagnosen oder Pflegeproblemen vorliegen. Gemein ist beiden Formen, dass Pflege aufgrund dieser Zustände aktiv wird. Das bedeutet, dass eine Pflegediagnose zumeist eine Pflegeintervention nach sich zieht. Folgende internationale Klassifikationen stehen (kostenpflichtig) zur Verfügung: International Classification of Nursing Pracitce (ICNP), NANDA-I Diagnoses, International Classification of Functioning, Disability and Health (ICF), Clinical Care Classification (CCC). Auf nationaler Ebene können neben den Übersetzungen der internationalen Klassifikationen folgende Terminologien (ggf. kostenplfichtig) genutzt werden: apenio bzw. European Nursing Care Pathways (ENP).
Beispiel
<act classCode="ACT" moodCode="EVN">
  <templateId root="1.2.276.0.76.10.4001"/>
  <statusCode code="active"/>
  <entryRelationship>
    <observation>
      <templateId root="2.999.888.777.22.77.10.19"/>
      <code code="CAREDX" codeSystem="1.2.276.0.76.5.342"/>
      <value code="A01.5" codeSystem="2.16.840.1.113883.6.236" displayName="Beeinträchtigung der körperlichen Mobilität" codeSystemName="Clinical Care Classification"/>
    </observation>
  </entryRelationship>
</act>
Beispiel
<act classCode="ACT" moodCode="EVN">
  <templateId root="1.2.276.0.76.10.4001"/>
  <statusCode code="active"/>
  <entryRelationship>
    <observation>
      <templateId root="2.999.888.777.22.77.10.19"/>
      <code code="CAREDX" codeSystem="1.2.276.0.76.5.342"/>
      <value code="10001219" codeSystem="2.16.840.1.113883.6.97" displayName="Impaired Mobility" codeSystemName="Intermational Classification of Nursing Practice"/>
    </observation>
  </entryRelationship>
</act>
ItemDTCardConfDescLabel
hl7:act
0 .. *(PflegediagnoseEntry)
Treetree.png@classCode
1 .. 1FACT
Treetree.png@moodCode
1 .. 1FEVN
Treetree.pnghl7:templateId
II1 .. 1R(PflegediagnoseEntry)
Treeblank.pngTreetree.png@root
1 .. 1F1.2.276.0.76.10.4001
Treetree.pnghl7:statusCode
CS1 .. 1M(PflegediagnoseEntry)
Treeblank.pngTreetree.png@code
1 .. 1Factive
Treetree.pnghl7:entryRelationship
1 .. 1M(PflegediagnoseEntry)
Treeblank.pngTreetree.pnghl7:observation
1 .. 1M(PflegediagnoseEntry)
Treeblank.pngTreeblank.pngTreetree.pnghl7:templateId
1 .. 1M(PflegediagnoseEntry)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
1 .. 1F2.999.888.777.22.77.10.19
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE1 .. 1M(PflegediagnoseEntry)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
1 .. 1FCAREDX
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 .. 1F1.2.276.0.76.5.342
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD1 .. 1M(PflegediagnoseEntry)
CONF
@codeSystem muss "2.16.840.1.113883.6.97" sein
oder
@codeSystem muss "2.16.840.1.113883.6.204" sein
oder
@codeSystem muss "2.16.840.1.113883.6.254" sein
oder
@codeSystem muss "2.16.840.1.113883.6.236" sein
oder
@codeSystem muss "1.2.276.0.76.3.1.125.1" sein
oder
@codeSystem muss "1.2.276.0.76.5.407" sein