|
|
| (6 dazwischenliegende Versionen desselben Benutzers werden nicht angezeigt) |
| Zeile 1: |
Zeile 1: |
| − | <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">Pflegeprozess Section<i> / NursingProcessSection</i></td></tr><tr><th align="left">Id</th><td align="left" style="background-color: #F6F3EE">1.2.276.0.76.10.3003</td></tr><tr><th align="left">Klassifikation</th><td align="left" style="background-color: #F6F3EE">CDA section level template</td></tr><tr><th align="left">Kontext</th><td align="left" style="background-color: #F6F3EE">Elternknoten des Template-Element mit Id 1.2.276.0.76.10.3003</td></tr><tr><th align="left"> Version </th><td align="left" style="background-color: #F6F3EE"> gültig ab 2013‑01‑09 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> Hier werden die pflegespezifischen Informationen anhand des Pflegeprozesses dargestellt. Die Informationen aus dem Pflegeprozess können grundsätzlich in drei Stufen unterschieden werden. Es gibt zum einen befundorientierte Informationen zu Score- Werten bzw. Assessments, Pflegediagnosen bzw. Pflegeproblemen und Pflegezielen. Eine Information in einem dieser Konzepte kann optional eine Information in dem Konzept Pflegemaßnahmen auslösen. Letztlich wird so dargestellt, dass jeder pflegerischen Handlung mindestens ein Grund oder Auslöser zugeordnet werden muss. Eine pflegerische Maßnahme kann somit nicht isoliert stehen. Gleichzeitig kann jedem Grund oder Auslöser eine oder mehrere pflegerische Maßnahmen zugeordnet werden. Als dritte Stufe kann jeder pflegerischen Maßnahme eine Information zum Ergebnis folgen. Auch hiermit wird wieder gewährleistet, dass ein pflegerisches Ergebnis nicht alleine steht, sondern nur in Verbindung mit einer Maßnahme existiert. <br> Diese Sektion enthält selbst keine Daten, sondern beinhaltet Untersektionen zur Darstellung der einzelnen Schritte des Pflegeprozesses.<br> Es MUSS mindestens eine Untersektion angegeben sein.</td></tr><tr valign="top"><th align="left">Benutzt von / Benutzt</th><td valign="top" colspan="3"><table class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td class="toggler" colspan="2" height="30px">Benutzt von / Benutzt 4 Templates</td></tr><tr><td colspan="2"><div class="toggle"><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="6" style="background: transparent;"><tr><th width="20%" align="left">Benutzt Template-Id</th><th width="60%" align="left">Name</th><th width="20%" align="left">Version</th></tr><tr><td align="left">1.2.276.0.76.10.3004</td><td align="left"><i>NursingDiagnosisSection</i></td><td align="left">2013‑01‑09</td></tr><tr><td align="left">1.2.276.0.76.10.3006</td><td align="left"><i>NursingGoalSection</i></td><td align="left">2012‑01‑09</td></tr><tr><td align="left">1.2.276.0.76.10.3010</td><td align="left"><i>NursingInterventionSection</i></td><td align="left">2013‑01‑10</td></tr><tr><td align="left">1.2.276.0.76.10.3011</td><td align="left"><i>NursingOutcomeSection</i></td><td align="left">2013‑01‑10</td></tr></table></div></td></tr></table></td></tr><tr class="explabel" valign="top"><td>Beispiel</td><td class="explabelblue"><tt><div><span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">></span><div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.3003</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">34746-8</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">></span><span class="pptext">Pflegeprozess</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">></span></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">component</span><span class="ppsign">></span><div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">></span><div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.3.999</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">--example only--</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">></span></div> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">component</span><span class="ppsign">></span></div><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">></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:section<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 .. *</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE">(NursingProcessSection)</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 .. 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">(NursingProcessSection)</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 .. 1</td><td>F</td><td colspan="2">1.2.276.0.76.10.3003</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 .. 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">(NursingProcessSection)</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 .. 1</td><td>F</td><td colspan="2">1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1</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: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 .. 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">(NursingProcessSection)</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 .. 1</td><td>F</td><td colspan="2">34746-8</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>codeSystem<br></strong></tt></td></tr></table></td><td></td><td>1 .. 1</td><td>F</td><td colspan="2">2.16.840.1.113883.6.1 (LOINC)</td></tr><tr class="explabel" valign="top"><td style="background-color: white"></td><td>Beispiel</td><td class="explabelblue" colspan="4"><tt><div><span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">34746-8</span><span class="ppsign">"</span> <span class="ppattribute">name</span><span class="ppsign">="</span><span class="ppcontent">Nursing Evaluation and Management Note</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Pflegeprozess</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div></tt></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:title<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>ST</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1 .. 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">(NursingProcessSection)</td></tr><tr bgcolor="#FFEEEE" valign="top"><td style="background-color: white"></td><td class="conf" valign="top">CONF </td><td colspan="4" style="background-color: white"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr valign="top"><td>Elementinhalt muss "Pflegeprozess" sein</td></tr></table></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:text<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>ED</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1 .. 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">(NursingProcessSection)</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:component<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 .. *</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td>Mögliche Untersektionen: <ul> <li>Pflegediagnose</li> <li>Pflegerisches Score</li> <li>Pflegeziel</li> </ul> </td><td style="background-color: #FFEEEE">(NursingProcessSection)</td></tr><tr bgcolor="#FFEEEE" valign="top"><td style="background-color: white"></td><td style="background-color: #FFEEEE">Beinhaltet</td><td style="background-color: #FFEEAA" colspan="3">1.2.276.0.76.10.3004 <i>Pflegediagnose Section</i> (2013‑01‑09) mit überschriebener Kardinalität 1 .. * Required Notwendig</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:section<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 .. 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">(NursingProcessSection)</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>II</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>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">(NursingProcessSection)</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:component<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 .. *</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td>Mögliche Untersektionen: <ul> <li>Pflegediagnose</li> <li>Pflegerisches Score</li> <li>Pflegeziel</li> </ul> </td><td style="background-color: #FFEEEE">(NursingProcessSection)</td></tr><tr bgcolor="#FFEEEE" valign="top"><td style="background-color: white"></td><td style="background-color: #FFEEEE">Beinhaltet</td><td style="background-color: #FFEEAA" colspan="3">1.2.276.0.76.10.3006 <i>Pflegeziel Section</i> (2012‑01‑09) mit überschriebener Kardinalität 1 .. * Required Notwendig</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:section<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 .. 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">(NursingProcessSection)</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>II</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>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">(NursingProcessSection)</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:component<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 .. *</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td>Mögliche Untersektionen: <ul> <li>Pflegediagnose</li> <li>Pflegerisches Score</li> <li>Pflegeziel</li> </ul> </td><td style="background-color: #FFEEEE">(NursingProcessSection)</td></tr><tr bgcolor="#FFEEEE" valign="top"><td style="background-color: white"></td><td style="background-color: #FFEEEE">Beinhaltet</td><td style="background-color: #FFEEAA" colspan="3">1.2.276.0.76.10.3010 <i>Pflegeintervention Section</i> (2013‑01‑10) mit überschriebener Kardinalität 1 .. * Required Notwendig</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:section<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 .. 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">(NursingProcessSection)</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>II</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>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">(NursingProcessSection)</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:component<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 .. *</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td>Mögliche Untersektionen: <ul> <li>Pflegediagnose</li> <li>Pflegerisches Score</li> <li>Pflegeziel</li> </ul> </td><td style="background-color: #FFEEEE">(NursingProcessSection)</td></tr><tr bgcolor="#FFEEEE" valign="top"><td style="background-color: white"></td><td style="background-color: #FFEEEE">Beinhaltet</td><td style="background-color: #FFEEAA" colspan="3">1.2.276.0.76.10.3011 <i>Pflegeergebnis Section</i> (2013‑01‑10) mit überschriebener Kardinalität 1 .. * Required Notwendig</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:section<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 .. 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">(NursingProcessSection)</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>II</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>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">(NursingProcessSection)</td></tr></table></td></tr></table>
| + | #REDIRECT [[1.2.276.0.76.10.3003/static-2013-01-09T000000]] |
| | + | <!-- NursingProcessSection --> |
| | + | <!-- ****** CAUTION Manual changes on this page are ineffective: the page is automagically generated by a transformer from an ART-DECOR project by a bot (ADBot). ****** --> |
| | + | <!--9cd3bc6e07a6f3fcfddec72563157aa850b6513a--> |
