1.2.276.0.76.10.4266/static-2017-11-20T220411: Unterschied zwischen den Versionen

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<table xmlns="http://www.w3.org/1999/xhtml" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.276.0.76.10.4266</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2017‑11‑20 22:04:11</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Entwurf</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;"></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">AUDiagnosisObservation</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">AU-Diagnosis Observation</td></tr><td style="text-align: left;" colspan="4"><table id="templateDescTable" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Beschreibung</td></tr><tr><td><div>Dieses Template spiegelt eine konkrete Beobachtung über das Problem bzw. die Diagnose eines Patienten wider. Weil es sich um eine abgeschlossene Beobachtung handelt, ist der statusCode immer "completed". </div></td></tr></table></td><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Kontext</th><td style="text-align: left;" colspan="3">Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4266</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Entry Level Template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Offen/Geschlossen</th><td style="text-align: left;" colspan="3">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Benutzt</th><td style="text-align: left;" colspan="3"><table width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt 2 Templates</td></tr><tr><td><div><table width="100%" border="0" cellspacing="1" cellpadding="3" class="artdecor " style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Benutzt</th><th style="width: 1%; text-align: left;"> als </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.2.276.0.76.10.90026</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Lateralität</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.276.0.76.10.90027</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Diagnosesicherheit</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beziehung</th><td style="text-align: left;" colspan="3">Spezialisierung: Template 1.2.276.0.76.10.4080 <i>Diagnose Observation </i> (2015‑12‑06) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">hl7de-</div></span><br />Spezialisierung: Template 2.16.840.1.113883.10.12.303 <i>CDA Observation </i> (2005‑09‑07) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">ad1bbr-</div></span><br />Adaptation: Template 2.16.840.1.113883.10.20.22.4.4 <i>Problem Observation (V3) </i> (2015‑08‑01) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">ccda-</div></span><br />Spezialisierung: Template 1.2.276.0.76.10.4075 <i>Problem Observation </i> (2015‑12‑06) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">hl7de-</div></span></td></tr><tr class="explabel " style="vertical-align: top;"><th class="" style="width: 20em; text-align: left;">Beispiel</th><td colspan="3" class="explabelblue"><table width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Beispiel</span></td></tr><tr><td><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">observation</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.4266</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">fa8a6ff8-ed4b-4f7e-82c3-e98e58b45d88</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">75324-4</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">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">reference</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">completed</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">low</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">high</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">CD</span><span class="ppsign">"</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">A05.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.413</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Botulismus</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span><span class="pptext">Fleisch- / Wurstvergiftung</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">qualifier</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- include template 1.2.276.0.76.10.90026 'Lateralität' (dynamic) .. O --&gt;<br /></span></span><span style="display: block;">    <span style="color:green">&lt;!-- include template 1.2.276.0.76.10.90027 'Diagnosesicherheit' (dynamic) .. O --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">translation</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">value</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span></span></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Kard</th><th style="width: 2em; text-align: left;">Konf</th><th style="text-align: left;">Beschreibung</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:observation<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@classCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">OBS</td></tr><tr><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@moodCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@negationInd<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>bl</td><td><span><strong>0 … 1</strong></span></td><td> </td><td style="vertical-align: top;" colspan="2">Zur Angabe eines Ausschlusses einer Diagnose wird negationInd=true gesetzt</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:templateId<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@root<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.276.0.76.10.4266</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:id<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">75324-4</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@codeSystem<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.6.1 (LOINC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:text<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>ED</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Textform, enthält hier lediglich reference in den Text der Section</td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:reference<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>URL</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@value<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td></td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2">#diag-{generierteID}, z.B.: #diag-1</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:statusCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td rowspan="1" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">completed</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:effectiveTime<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>effectiveTime wird auch als "biologisch relevante Zeit" bezeichnet und ist der Zeitpunkt oder Zeitraum, für den die Beobachtung für den Patienten gilt.<br /><div>Beispiel: Für Gesundheitsdienstleister, die einen Patienten heute in der Klinik sehen,</div><div>anamnestisch einen Herzinfarkt erheben, der vor fünf Jahren stattgefunden</div><div>hat, ist effectiveTime: vor fünf Jahren.</div> Die effectiveTime hier ist die definitive Angabe, ob die zugrunde liegende Erkrankung behoben ist. effectiveTime.low ist der Beginn des Problems für den Patienten. Wenn das Problem noch nicht gelöst ist, wird effectiveTime.high nicht gesetzt. Wenn bekannt ist, dass das Problem gelöst worden ist, dann ist effectiveTime.high vorhanden. Wenn der genaue Zeitpunkt          der Lösung des Problems nicht bekannt ist, dann ist effectiveTime.high vorhanden und auf nullFlavor "UNK" gesetzt. </td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:low<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Das low Element gibt das Datum an, seit wann der Patient diese Diagnose hat</td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:high<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Das high Element gibt das Datum an, seit wann der Patient diese Diagnose nicht mehr hat</td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:value<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CD</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>muss aus der Konzeptdomäne "Diagnosecodes" gewählt werden</td></tr></table></td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Beispiel</td><td colspan="4" class="explabelblue"><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">CD</span><span class="ppsign">"</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">A05.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.413</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Botulismus</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span><span class="pptext">Fleisch- / Wurstvergiftung</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">value</span><span class="ppsign">&gt;</span></span></span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:qualifier<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CR</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td colspan="2"> von 1.2.276.0.76.10.90026 <i>Lateralität</i> (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:qualifier<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CR</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Seitenlokalisation</td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo  <i> [hl7:name/&#8203;@code&#8203;=&#8203;'20228-3']</i></td><td></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="3">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">vomgt-data&#8203;element-916</td><td style="vertical-align: top;" title="AR-Antrag / Clinical Data / AR_B_(Befundbericht) / Funktionsdiagnosen / ">[[File:Kyellow.png|14px]] DiagnoseSeitenlokalisation </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] KV-Mustersammlung  </td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">vomgt-data&#8203;element-744</td><td style="vertical-align: top;" title="Muster 02a: Verordnung von Krankenhausbehandlung / Diagnosen/Begründung der Notwendigkeit / Diagnose-Liste / ">[[File:Kyellow.png|14px]] Lateralität </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] KV-Mustersammlung  </td></tr></table></td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Beispiel</td><td colspan="4" class="explabelblue"><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">name</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">20228-3</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">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">L</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.412</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span></span></span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:name<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CV</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">20228-3</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@codeSystem<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.6.1 (LOINC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:value<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CV</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.276.0.76.11.412 <i>Lateralität </i>(DYNAMIC)</td></tr></table></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td colspan="2"> von 1.2.276.0.76.10.90027 <i>Diagnosesicherheit</i> (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:qualifier<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CR</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Optionale Angabe der Diagnosesicherheit (laut §295 SGB V) als Qualifier-Kind-Element des value-Elements des Problems (Diagnose).</td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo  <i> [hl7:name/&#8203;@code&#8203;=&#8203;'8']</i></td><td></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">vomgt-data&#8203;element-745</td><td style="vertical-align: top;" title="Muster 02a: Verordnung von Krankenhausbehandlung / Diagnosen/Begründung der Notwendigkeit / Diagnose-Liste / ">[[File:Kyellow.png|14px]] Sicherheit </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] KV-Mustersammlung  </td></tr></table></td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Beispiel</td><td colspan="4" class="explabelblue"><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">name</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">8</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.3.7.1.0</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">G</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.3.1.1.5.1.21</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span></span></span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:name<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CV</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">8</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@codeSystem<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.3.7.1.0</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:value<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CV</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.276.0.76.11.121 <i>S_ICD_DIAGNOSESICHERHEIT </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:translation<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td></td><td><span><strong>0 … 1</strong></span></td><td> </td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="2" class="defvar">Variable let</td><td style="background-color: #FFEEEE;">Name</td><td colspan="2">sgbv295q</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Value</td><td colspan="2">hl7:value/hl7:qualifier[hl7:name/@codeSystem='2.16.840.1.113883.3.7.1.0']/hl7:value/@code</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2"> error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">not($sgbv295q='G') or hl7:participant[@typeCode='AUTHEN']</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">Wenn Zusatzkennzeichen 'G' nach §295 SGB V angegeben wird, muss ein participant mit @typeCode='AUTHEN' vorhanden sein.</span></td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2"> error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">not($sgbv295q='A') or @negationInd='true'</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">Wenn Zusatzkennzeichen 'A' nach §295 SGB V angegeben wird, muss bei der Observation @negationInd='true' angegeben sein.</span></td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2"> error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">not($sgbv295q='Z') or hl7:effectiveTime/hl7:high</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">Wenn Zusatzkennzeichen 'Z' nach §295 SGB V angegeben wird, muss bei der Observation effectiveTime.high angegeben sein.</span></td><td style="background-color: white;"> </td></tr></table></td></tr></table>
+
<table xmlns="http://www.w3.org/1999/xhtml" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.276.0.76.10.4266</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2017‑11‑20 22:04:11</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Entwurf</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;"></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">AUDiagnosisObservation</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">AU-Diagnosis Observation</td></tr><td style="text-align: left;" colspan="4"><table id="templateDescTable" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Beschreibung</td></tr><tr><td><div>Dieses Template spiegelt eine konkrete Beobachtung über das Problem bzw. die Diagnose eines Patienten wider. Weil es sich um eine abgeschlossene Beobachtung handelt, ist der statusCode immer "completed". </div></td></tr></table></td><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Kontext</th><td style="text-align: left;" colspan="3">Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4266</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Entry Level Template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Offen/Geschlossen</th><td style="text-align: left;" colspan="3">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Benutzt</th><td style="text-align: left;" colspan="3"><table width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt 2 Templates</td></tr><tr><td><div><table width="100%" border="0" cellspacing="1" cellpadding="3" class="artdecor " style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Benutzt</th><th style="width: 1%; text-align: left;"> als </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.2.276.0.76.10.90026</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Lateralität</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.276.0.76.10.90027</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Diagnosesicherheit</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beziehung</th><td style="text-align: left;" colspan="3">Spezialisierung: Template 1.2.276.0.76.10.4080 <i>Diagnose Observation </i> (2015‑12‑06) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">hl7de-</div></span><br />Spezialisierung: Template 2.16.840.1.113883.10.12.303 <i>CDA Observation </i> (2005‑09‑07) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">ad1bbr-</div></span><br />Adaptation: Template 2.16.840.1.113883.10.20.22.4.4 <i>Problem Observation (V3) </i> (2015‑08‑01) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">ccda-</div></span><br />Spezialisierung: Template 1.2.276.0.76.10.4075 <i>Problem Observation </i> (2015‑12‑06) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">hl7de-</div></span></td></tr><tr class="explabel " style="vertical-align: top;"><th class="" style="width: 20em; text-align: left;">Beispiel</th><td colspan="3" class="explabelblue"><table width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Beispiel</span></td></tr><tr><td><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">observation</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.4266</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">fa8a6ff8-ed4b-4f7e-82c3-e98e58b45d88</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">75324-4</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">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">reference</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">completed</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">low</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">high</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">CD</span><span class="ppsign">"</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">A05.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.413</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Botulismus</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span><span class="pptext">Fleisch- / Wurstvergiftung</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">qualifier</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- include template 1.2.276.0.76.10.90026 'Lateralität' (dynamic) .. O --&gt;<br /></span></span><span style="display: block;">    <span style="color:green">&lt;!-- include template 1.2.276.0.76.10.90027 'Diagnosesicherheit' (dynamic) .. O --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">translation</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">value</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span></span></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Kard</th><th style="width: 2em; text-align: left;">Konf</th><th style="text-align: left;">Beschreibung</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:observation<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@classCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">OBS</td></tr><tr><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@moodCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@negationInd<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>bl</td><td><span><strong>0 … 1</strong></span></td><td> </td><td style="vertical-align: top;" colspan="2">Zur Angabe eines Ausschlusses einer Diagnose wird negationInd=true gesetzt</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:templateId<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@root<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.276.0.76.10.4266</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:id<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">75324-4</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@codeSystem<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.6.1 (LOINC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:text<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>ED</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Textform, enthält hier lediglich reference in den Text der Section</td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:reference<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>URL</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@value<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td></td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2">#diag-{generierteID}, z.B.: #diag-1</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:statusCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td rowspan="1" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">completed</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:effectiveTime<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>effectiveTime wird auch als "biologisch relevante Zeit" bezeichnet und ist der Zeitpunkt oder Zeitraum, für den die Beobachtung für den Patienten gilt.<br /><div>Beispiel: Für Gesundheitsdienstleister, die einen Patienten heute in der Klinik sehen,</div><div>anamnestisch einen Herzinfarkt erheben, der vor fünf Jahren stattgefunden</div><div>hat, ist effectiveTime: vor fünf Jahren.</div> Die effectiveTime hier ist die definitive Angabe, ob die zugrunde liegende Erkrankung behoben ist. effectiveTime.low ist der Beginn des Problems für den Patienten. Wenn das Problem noch nicht gelöst ist, wird effectiveTime.high nicht gesetzt. Wenn bekannt ist, dass das Problem gelöst worden ist, dann ist effectiveTime.high vorhanden. Wenn der genaue Zeitpunkt          der Lösung des Problems nicht bekannt ist, dann ist effectiveTime.high vorhanden und auf nullFlavor "UNK" gesetzt. </td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:low<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Das low Element gibt das Datum an, seit wann der Patient diese Diagnose hat</td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:high<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Das high Element gibt das Datum an, seit wann der Patient diese Diagnose nicht mehr hat</td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:value<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CD</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>muss aus der Konzeptdomäne "Diagnosecodes" gewählt werden</td></tr></table></td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Beispiel</td><td colspan="4" class="explabelblue"><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">CD</span><span class="ppsign">"</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">A05.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.413</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Botulismus</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span><span class="pptext">Fleisch- / Wurstvergiftung</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">value</span><span class="ppsign">&gt;</span></span></span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:qualifier<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CR</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td colspan="2"> von 1.2.276.0.76.10.90026 <i>Lateralität</i> (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:qualifier<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CR</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Seitenlokalisation</td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo  <i> [hl7:name/&#8203;@code&#8203;=&#8203;'20228-3']</i></td><td></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="3">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">vomgt-data&#8203;element-916</td><td style="vertical-align: top;" title="AR-Antrag / Clinical Data / AR_B_(Befundbericht) / Funktionsdiagnosen / ">[[File:Kyellow.png|14px]] DiagnoseSeitenlokalisation </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] KV-Mustersammlung  </td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">vomgt-data&#8203;element-744</td><td style="vertical-align: top;" title="Muster 02a: Verordnung von Krankenhausbehandlung / Diagnosen/Begründung der Notwendigkeit / Diagnose-Liste / ">[[File:Kyellow.png|14px]] Lateralität </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] KV-Mustersammlung  </td></tr></table></td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Beispiel</td><td colspan="4" class="explabelblue"><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">name</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">20228-3</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">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">L</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.412</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span></span></span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:name<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CV</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">20228-3</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@codeSystem<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.6.1 (LOINC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:value<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CV</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.276.0.76.11.412 <i>Lateralität </i>(DYNAMIC)</td></tr></table></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td colspan="2"> von 1.2.276.0.76.10.90027 <i>Diagnosesicherheit</i> (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:qualifier<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CR</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Optionale Angabe der Diagnosesicherheit (laut §295 SGB V) als Qualifier-Kind-Element des value-Elements des Problems (Diagnose).</td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo  <i> [hl7:name/&#8203;@code&#8203;=&#8203;'8']</i></td><td></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">vomgt-data&#8203;element-745</td><td style="vertical-align: top;" title="Muster 02a: Verordnung von Krankenhausbehandlung / Diagnosen/Begründung der Notwendigkeit / Diagnose-Liste / ">[[File:Kyellow.png|14px]] Sicherheit </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] KV-Mustersammlung  </td></tr></table></td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Beispiel</td><td colspan="4" class="explabelblue"><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">name</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">8</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.3.7.1.0</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">value</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">G</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.3.1.1.5.1.21</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span></span></span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:name<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CV</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">8</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@codeSystem<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.3.7.1.0 (Sciphox)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:value<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CV</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.276.0.76.11.121 <i>S_ICD_DIAGNOSESICHERHEIT </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:translation<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(AUD...ion)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td></td><td><span><strong>0 … 1</strong></span></td><td> </td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="2" class="defvar">Variable let</td><td style="background-color: #FFEEEE;">Name</td><td colspan="2">sgbv295q</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Value</td><td colspan="2">hl7:value/hl7:qualifier[hl7:name/@codeSystem='2.16.840.1.113883.3.7.1.0']/hl7:value/@code</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2"> error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">not($sgbv295q='G') or hl7:participant[@typeCode='AUTHEN']</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">Wenn Zusatzkennzeichen 'G' nach §295 SGB V angegeben wird, muss ein participant mit @typeCode='AUTHEN' vorhanden sein.</span></td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2"> error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">not($sgbv295q='A') or @negationInd='true'</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">Wenn Zusatzkennzeichen 'A' nach §295 SGB V angegeben wird, muss bei der Observation @negationInd='true' angegeben sein.</span></td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2"> error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">not($sgbv295q='Z') or hl7:effectiveTime/hl7:high</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">Wenn Zusatzkennzeichen 'Z' nach §295 SGB V angegeben wird, muss bei der Observation effectiveTime.high angegeben sein.</span></td><td style="background-color: white;"> </td></tr></table></td></tr></table>
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<!--d12baf02ab8a027f909bbb95e26e176565836814-->

Version vom 28. Januar 2021, 11:19 Uhr

Id1.2.276.0.76.10.4266Gültigkeit2017‑11‑20 22:04:11
StatusKyellow.png EntwurfVersions-Label
NameAUDiagnosisObservationBezeichnungAU-Diagnosis Observation
Beschreibung
Dieses Template spiegelt eine konkrete Beobachtung über das Problem bzw. die Diagnose eines Patienten wider. Weil es sich um eine abgeschlossene Beobachtung handelt, ist der statusCode immer "completed".
KontextElternknoten des Template-Element mit Id 1.2.276.0.76.10.4266
KlassifikationCDA Entry Level Template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Benutzt
Benutzt 2 Templates
Benutzt als NameVersion
1.2.276.0.76.10.90026InklusionKyellow.png LateralitätDYNAMIC
1.2.276.0.76.10.90027InklusionKyellow.png DiagnosesicherheitDYNAMIC
BeziehungSpezialisierung: Template 1.2.276.0.76.10.4080 Diagnose Observation (2015‑12‑06)
ref
hl7de-

Spezialisierung: Template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-

Adaptation: Template 2.16.840.1.113883.10.20.22.4.4 Problem Observation (V3) (2015‑08‑01)
ref
ccda-

Spezialisierung: Template 1.2.276.0.76.10.4075 Problem Observation (2015‑12‑06)
ref
hl7de-
Beispiel
Beispiel
<observation>
  <templateId root="1.2.276.0.76.10.4266"/>  <id root="fa8a6ff8-ed4b-4f7e-82c3-e98e58b45d88"/>  <code code="75324-4" codeSystem="2.16.840.1.113883.6.1"/>  <text>
    <reference/>  </text>
  <statusCode code="completed"/>  <effectiveTime>
    <low/>    <high/>  </effectiveTime>
  <value xsi:type="CD" code="A05.1" codeSystem="1.2.276.0.76.5.413" displayName="Botulismus">
    <originalText>Fleisch- / Wurstvergiftung</originalText>    <qualifier/>    <!-- include template 1.2.276.0.76.10.90026 'Lateralität' (dynamic) .. O -->
    <!-- include template 1.2.276.0.76.10.90027 'Diagnosesicherheit' (dynamic) .. O -->
    <translation/>  </value>
</observation>
ItemDTKardKonfBeschreibungLabel
hl7:observation
(AUD...ion)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 Zur Angabe eines Ausschlusses einer Diagnose wird negationInd=true gesetzt
Treetree.pnghl7:templateId
II1 … 1M(AUD...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F1.2.276.0.76.10.4266
Treetree.pnghl7:id
1 … *(AUD...ion)
Treetree.pnghl7:code
1 … 1M(AUD...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F75324-4
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:text
ED0 … 1Textform, enthält hier lediglich reference in den Text der Section(AUD...ion)
Treeblank.pngTreetree.pnghl7:reference
URL1 … 1(AUD...ion)
Treeblank.pngTreeblank.pngTreetree.png@value
1 … 1R#diag-{generierteID}, z.B.: #diag-1
Treetree.pnghl7:statusCode
1 … 1M(AUD...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1Fcompleted
Treetree.pnghl7:effectiveTime
1 … 1ReffectiveTime wird auch als "biologisch relevante Zeit" bezeichnet und ist der Zeitpunkt oder Zeitraum, für den die Beobachtung für den Patienten gilt.
Beispiel: Für Gesundheitsdienstleister, die einen Patienten heute in der Klinik sehen,
anamnestisch einen Herzinfarkt erheben, der vor fünf Jahren stattgefunden
hat, ist effectiveTime: vor fünf Jahren.
Die effectiveTime hier ist die definitive Angabe, ob die zugrunde liegende Erkrankung behoben ist. effectiveTime.low ist der Beginn des Problems für den Patienten. Wenn das Problem noch nicht gelöst ist, wird effectiveTime.high nicht gesetzt. Wenn bekannt ist, dass das Problem gelöst worden ist, dann ist effectiveTime.high vorhanden. Wenn der genaue Zeitpunkt der Lösung des Problems nicht bekannt ist, dann ist effectiveTime.high vorhanden und auf nullFlavor "UNK" gesetzt.
(AUD...ion)
Treeblank.pngTreetree.pnghl7:low
1 … 1RDas low Element gibt das Datum an, seit wann der Patient diese Diagnose hat(AUD...ion)
Treeblank.pngTreetree.pnghl7:high
0 … 1Das high Element gibt das Datum an, seit wann der Patient diese Diagnose nicht mehr hat(AUD...ion)
Treetree.pnghl7:value
CD1 … 1R(AUD...ion)
 CONF
muss aus der Konzeptdomäne "Diagnosecodes" gewählt werden
 Beispiel<value xsi:type="CD" code="A05.1" codeSystem="1.2.276.0.76.5.413" displayName="Botulismus">
  <originalText>Fleisch- / Wurstvergiftung</originalText></value>
Treeblank.pngTreetree.pnghl7:qualifier
CR0 … *(AUD...ion)
Eingefügt von 1.2.276.0.76.10.90026 Lateralität (DYNAMIC)
Treeblank.pngTreetree.pnghl7:qualifier
CR0 … 1Seitenlokalisation(AUD...ion)
wo [hl7:name/​@code​=​'20228-3']
 
Target.png
vomgt-data​element-916Kyellow.png DiagnoseSeitenlokalisation Kyellow.png KV-Mustersammlung
vomgt-data​element-744Kyellow.png Lateralität Kyellow.png KV-Mustersammlung
 Beispiel<qualifier>
  <name code="20228-3" codeSystem="2.16.840.1.113883.6.1"/>  <value code="L" codeSystem="1.2.276.0.76.5.412"/></qualifier>
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV1 … 1M(AUD...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF1 … 1F20228-3
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CV1 … 1R(AUD...ion)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 1.2.276.0.76.11.412 Lateralität (DYNAMIC)
Eingefügt von 1.2.276.0.76.10.90027 Diagnosesicherheit (DYNAMIC)
Treeblank.pngTreetree.pnghl7:qualifier
CR0 … 1Optionale Angabe der Diagnosesicherheit (laut §295 SGB V) als Qualifier-Kind-Element des value-Elements des Problems (Diagnose).(AUD...ion)
wo [hl7:name/​@code​=​'8']
 
Target.png
vomgt-data​element-745Kyellow.png Sicherheit Kyellow.png KV-Mustersammlung
 Beispiel<qualifier>
  <name code="8" codeSystem="2.16.840.1.113883.3.7.1.0"/>  <value code="G" codeSystem="1.2.276.0.76.3.1.1.5.1.21"/></qualifier>
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV1 … 1M(AUD...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF1 … 1F8
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.3.7.1.0 (Sciphox)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CV1 … 1M(AUD...ion)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 1.2.276.0.76.11.121 S_ICD_DIAGNOSESICHERHEIT (DYNAMIC)
Treeblank.pngTreetree.pnghl7:translation
0 … *(AUD...ion)
Treeblank.pngTreeblank.pngTreetree.png@code
0 … 1 
 Variable letNamesgbv295q 
 Valuehl7:value/hl7:qualifier[hl7:name/@codeSystem='2.16.840.1.113883.3.7.1.0']/hl7:value/@code 
 Schematron assertrole error 
 testnot($sgbv295q='G') or hl7:participant[@typeCode='AUTHEN'] 
 MeldungWenn Zusatzkennzeichen 'G' nach §295 SGB V angegeben wird, muss ein participant mit @typeCode='AUTHEN' vorhanden sein. 
 Schematron assertrole error 
 testnot($sgbv295q='A') or @negationInd='true' 
 MeldungWenn Zusatzkennzeichen 'A' nach §295 SGB V angegeben wird, muss bei der Observation @negationInd='true' angegeben sein. 
 Schematron assertrole error 
 testnot($sgbv295q='Z') or hl7:effectiveTime/hl7:high 
 MeldungWenn Zusatzkennzeichen 'Z' nach §295 SGB V angegeben wird, muss bei der Observation effectiveTime.high angegeben sein.