1.2.276.0.76.10.4080/static-2015-12-06T000000

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Template Diagnose Observation / DiagnoseObservation
Id1.2.276.0.76.10.4080
Version gültig ab 2015‑12‑06 Status Kyellow.png In Entwicklung
KlassifikationCDA Entry Level Template
KontextElternknoten des Template-Element mit Id 1.2.276.0.76.10.4080
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
BeschreibungEN-US.png This template reflects a discrete observation about a patient's problem. Because it is a discrete observation, it will have a statusCode of "completed". The effectiveTime, also referred to as the “biologically relevant time” is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of heart attack that occurred five years ago, the effectiveTime is five years ago. The effectiveTime of the Problem Observation is the definitive indication of whether or not the underlying condition is resolved. If the problem is known to be resolved, then an effectiveTime/high would be present. If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK".
Benutzt von / Benutzt
Benutzt von / Benutzt 8 Templates
Benutzt von Template-Id als NameVersion
1.2.276.0.76.10.4079ContainmentDiagnoseConcernAct Diagnose Concern Act2015‑12‑06
Benutzt Template-Id als NameVersion
1.2.276.0.76.10.90025InklusionCDAAuthorBody DYNAMIC
1.2.276.0.76.10.4077ContainmentAgeObservation DYNAMIC
1.2.276.0.76.10.4078ContainmentPrognosisObservation DYNAMIC
1.2.276.0.76.10.4076ContainmentPriorityPreference DYNAMIC
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Adaptation: Template 2.16.840.1.113883.10.20.22.4.4 (2015‑08‑01)
Spezialisierung: Template 1.2.276.0.76.10.4075 (2015‑12‑06)
Beispiel<observation classCode="OBS" moodCode="EVN">
  <!-- Diagnose Observation -->
  <templateId root="1.2.276.0.76.10.4080"/>
  <id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
  <code code="75324-" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis"/>
  <!-- The statusCode reflects the status of the observation itself -->
  <statusCode code="completed"/>
  <effectiveTime>
    <!-- Das low Element gibt das Datum an, seit wann der Patient diese Diagnose hat -->
    <low value="20130703"/>
    <!-- Das high Element gibt das Datum an, seit wann der Patient diese Diagnose nicht mehr hat -->
    <high value="20080814"/>
  </effectiveTime>
  <!--
Im value Element wird die kodierte Diagnose angegeben,
z. B. als ICD-10 GM 2016 (OID 1.2.276.0.76.5.430): J11.1 Grippe mit sonstigen Manifestationen an den Atemwegen, Viren nicht nachgewiesen
-->
  <value xsi:type="CD" code="J11.1" codeSystem="1.2.276.0.76.5.430" displayName="Grippe mit sonstigen Manifestationen an den Atemwegen, Viren nicht nachgewiesen"/>
  <author typeCode="AUT">
    <!-- optional: Autor der Diagnose -->
  </author>
</observation>
ItemDTKardKonfBeschreibungLabel
hl7:observation
(DiagnoseObservation)
Treetree.png@classCode
cs1 .. 1FOBS
Treetree.png@moodCode
cs1 .. 1FEVN
Treetree.png@negationInd
bl0 .. 1 
Treetree.pnghl7:templateId
1 .. 1M(DiagnoseObservation)
Treeblank.pngTreetree.png@root
uid1 .. 1F1.2.276.0.76.10.4080
Treetree.pnghl7:id
1 .. *(DiagnoseObservation)
Treetree.pnghl7:code
1 .. 1M(DiagnoseObservation)
Treeblank.pngTreetree.png@code
1 .. 1F75324-4
Treeblank.pngTreetree.png@codeSystem
1 .. 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treetree.pnghl7:statusCode
1 .. 1M(DiagnoseObservation)
Treeblank.pngTreetree.png@code
1 .. 1Fcompleted
Treetree.pnghl7:effectiveTime
1 .. 1MEN-US.png If the problem is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'. Therefore, the existence of an high element within a problem does indicate that the problem has been resolved.(DiagnoseObservation)
Treeblank.pngTreetree.pnghl7:low
1 .. 1MDas low Element gibt das Datum an, seit wann der Patient diese Diagnose hat(DiagnoseObservation)
Treeblank.pngTreetree.pnghl7:high
0 .. 1Das high Element gibt das Datum an, seit wann der Patient diese Diagnose nicht mehr hat(DiagnoseObservation)
Treetree.pnghl7:value
CD1 .. 1R(DiagnoseObservation)
 CONF
muss aus der Konzeptdomäne "Diagnosecodes" gewählt werden
Treeblank.pngTreetree.pnghl7:qualifier
0 .. *EN-US.png This value MAY contain zero or more [0..*] qualifier (CONF:1198-31870).

The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML.
(DiagnoseObservation)
Treeblank.pngTreetree.pnghl7:translation
0 .. *CONF:1198‑16749
Treeblank.pngTreeblank.pngTreetree.png@code
0 .. 1 
 EN-US.png MAY contain zero or one [0..1] @code (CodeSystem: ICD10CM urn:oid:2.16.840.1.113883.6.90 STATIC) (CONF:1198-16750).
Treetree.pnghl7:author
0 .. *R(DiagnoseObservation)
Eingefügt von 1.2.276.0.76.10.90025 CDA Author (Body) (DYNAMIC)
Treeblank.pngTreetree.png@typeCode
0 .. 1FAUT
Treeblank.pngTreetree.png@context​Control​Code
0 .. 1FOP
Treeblank.pngTreetree.pnghl7:functionCode
CE0 .. 1(DiagnoseObservation)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
Treeblank.pngTreetree.pnghl7:time
TS1 .. 1R(DiagnoseObservation)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 .. 1R(DiagnoseObservation)
Treeblank.pngTreeblank.pngTreetree.png@classCode
0 .. 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 .. *R(DiagnoseObservation)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 .. 1(DiagnoseObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 .. 1F2.16.840.1.113883.5.111 (Role Code)
Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 .. *(DiagnoseObservation)
Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 .. *(DiagnoseObservation)
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 .. 1(DiagnoseObservation)
Eingefügt von 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 .. 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 .. 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 .. 1(DiagnoseObservation)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 .. 1(DiagnoseObservation)
Eingefügt von 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 .. 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 .. 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 .. *(DiagnoseObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 .. 1(DiagnoseObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 .. *(DiagnoseObservation)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 .. 1(DiagnoseObservation)
Treetree.pnghl7:entryRelationship
0 .. 1(DiagnoseObservation)
Treeblank.pngTreetree.png@typeCode
cs1 .. 1FSUBJ
Treeblank.pngTreetree.png@inversionInd
bl1 .. 1Ftrue
 Beinhaltet 1.2.276.0.76.10.4077 Alter Observation (DYNAMIC)
Treetree.pnghl7:entryRelationship
0 .. 1(DiagnoseObservation)
Treeblank.pngTreetree.png@typeCode
cs1 .. 1FREFR
 Beinhaltet 1.2.276.0.76.10.4078 Prognose Observation (DYNAMIC)
Treetree.pnghl7:entryRelationship
0 .. *Wichtigkeit der Diagnose laut Einschätzung des Gesundheitsdienstleisters(DiagnoseObservation)
Treeblank.pngTreetree.png@typeCode
cs1 .. 1FREFR
 Beinhaltet 1.2.276.0.76.10.4076 Priorität Preference (DYNAMIC)