Foemig: Initialfassung zur Kommentierung

2013-06-14T13:59:51Z

Initialfassung zur Kommentierung

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{{DocumentPart}}

=CDA-Beispiel=

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<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<id extension="60878,34593" root="1.2.276.0.58"/>
<code code="????" codeSystem="2.16.840.1.113883.6.1" displayName="Medication Plan"/>
<title>Medikationsplan</title>
<effectiveTime value="20130426"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="de" />
<setId extension="D1" root="2.16.840.1.113883.3.933"/>
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<patientRole>
<id extension="65" root="2.16.840.1.113883.3.933"/>
<addr>
<streetName>Riedemannweg</streetName>
<houseNumber></houseNumber>
<postalCode>13627</postalCode>
<city>Berlin</city>
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<patient>
<name>
<given>Michaela</given>
<family>Mustermann</family>
</name>
<administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/>
<birthTime value="19361213"/>
</patient>
<providerOrganization>
<telecom use="WP" value="tel:(02421)27070"/>
<telecom use="WP" value="fax:(02421)2707120"/>
<addr>
<streetName>Hauptstraße</streetName>
<houseNumber>55</houseNumber>
<postalCode>01234</postalCode>
<city>Am Ort</city>
</addr>
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<author>

<time value="20070905"/>
<assignedAuthor>
<id extension="2112345" root="2.16.840.1.113883.3.933"/>
<assignedPerson>
<name>
<prefix>Dr. med.</prefix>
<given>Manfred</given>
<family>Überall</family>
</name>
</assignedPerson>
<representedOrganization>
<name>Praxis Dr. Überall</name>
<telecom use="WP" value="tel:(02421)27070"/>
<telecom use="WP" value="fax:(02421)2707120"/>
<addr>
<streetName>Kölner Landstr.</streetName>
<houseNumber>240</houseNumber>
<postalCode>52351</postalCode>
<city>Düren</city>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
<custodian> 
<assignedCustodian>
<representedCustodianOrganization>
<id extension="M345" root="1.2.276.0.58"/>
<name>Dr. med. Theo DURIA </name>
<telecom nullFlavor="UNK"/>
<addr>
<streetName>Kölner Landstr.</streetName>
<houseNumber>240</houseNumber>
<postalCode>52351</postalCode>
<city>Düren</city>
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<legalAuthenticator> 
<time value="20070905"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="2112345" root="2.16.840.1.113883.3.933"/>
<assignedPerson>
<name>
<prefix>Dr. med.</prefix>
<given>Theo</given>
<family>DURIA</family>
</name>
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<representedOrganization>
<name>Dr. med. Theo DURIA </name>
<telecom use="WP" value="tel:(02421)27070"/>
<telecom use="WP" value="fax:(02421)2707120"/>
<addr>
<streetName>Kölner Landstr.</streetName>
<houseNumber>240</houseNumber>
<postalCode>52351</postalCode>
<city>Düren</city>
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<component>
<section>
<code code="13133-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>
<table border="1">
<thead>
<tr>
<th>Wirkstoff</th>
<th>Handelsname</th>
<th>Stärke</th>
<th>Form</th>
<th>Mo</th>
<th>Mi</th>
<th>Ab</th>
<th>zN</th>
<th>Einheit</th>
<th>Hinweise</th>
<th>Grund</th>
</tr>
</thead>
<tbody>

<tr>
<td>Ramipril</td>
<td>Ramipril STADA® N1</td>
<td>5mg </td>
<td>Tab</td>
<td>1</td><td> 0</td><td>0</td><td></td>
<td>Stck</td>
<td> während der Mahlzeiten </td>
<td>Bluthochdruck</td>
</tr>
<tr>
<td>
Hydrochlorothiazid </td>
<td>HCT-dura® 25mg N2 </td>
<td>25mg </td>
<td>Tab</td>
<td> 1</td><td> 0</td><td> 0</td><td></td>
<td> Stck</td><td> während der Mahlzeiten </td>
<td>Bluthochdruck</td>
</tr>
<tr>
<td>Clopidogrel </td><td>Plavix® 75 mg N1 </td>
<td>75mg </td>
<td>Tab</td>
<td>0</td><td> 0</td><td> 1 </td><td></td><td>Stck </td>
<td>während der Mahlzeiten </td>
<td>art. Verschluss</td>
</tr>
<tr>
<td>Simvastatin </td>
<td>Simvalip® 20mg N2 </td>
<td>20mg </td><td>Tab</td>
<td>0</td><td> 0</td><td> 1 </td><td></td>
<td>Stck </td>
<td>nach der Mahlzeit </td>
<td>erhöhte Blutfette</td>
</tr>
<tr>
<td styleCode='Bold'>Anwendung unter die Haut</td>
</tr>
<tr>
<td>Insulin </td>
<td>human Insulin B. Braun Basal</td>
<td> </td>
<td>Spritze </td>
<td>20</td><td> 0 </td><td>10 </td><td></td>
<td>IE </td><td>sub cutan </td><td>Diabetes</td>
</tr>
<tr>
<td styleCode='Bold'>Bedarfsmedikation</td>
</tr>
<tr>
<td>Glyceroltrinitrat </td>
<td>Corangin® Nitrospray</td>
<td></td>
<td>Spray </td><td></td><td></td><td></td><td></td>
<td>max. 3 Hübe </td>
<td>akut </td>
<td>Herzschmerzen</td>
</tr>
<tr>
<td></td>
<td>Vivinox® stark </td>
<td></td>
<td>Tab</td>
<td>0 </td><td>0 </td><td>0 </td><td>1 </td>
<td>Stck </td>
<td>bei Bedarf</td>
<td>Schlaflosigkeit</td>
</tr>

</tbody>
</table>

</text>

<entry>
<observation classCode='OBS' moodCode='EVN' negationInd=' false'>
<code code='xxxx' displayName='xxxx' codeSystem='2.16.840.1.113883.6.96'
codeSystemName='SNOMED CT'/>
<statusCode code='completed'/>
<effectiveTime><low value='20130430'/><high value='20130430'/></effectiveTime>
<value xsi:type='ST' >MP|12.12.2012|1|1|n|
Michaela Mustermann|13.12.1936|
Dr. Manfred Überall|Hauptstraße 55|01234 Am Ort|04562-12345|m.ueberall@mein-netz.de|
4213891|Tab|100|Stck|während der Mahlzeiten|Bluthochdruck|
1167417|Tab|100|Stck|während der Mahlzeiten|Bluthochdruck|
4129423|Tab|001|Stck|während der Mahlzeiten|art. Verschluss|
1048871|Tab|001|Stck|nach der Mahlzeit|erhöhte Blutfette|
#416|
1058964|Spritze|20-0-10|IE|sub cutan|Diabetes|
#Bedarfsmedikation|
3842722|Spray|max. 3|Hübe|akut|Herzschmerzen|
2083906|Tab|0001|Stck|bei Bedarf|Schlaflosigkeit|
¦422|Bitte messen Sie Ihren Blutdruck täglich!|
013|DE</value>
</observation>
</entry>

</section>
</component>

<component>
<section>
<code code="xxxxxx" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Wichtige Angaben</title>
<text>
Bitte messen Sie Ihren Blutdruck täglich!
</text>
</section>
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[[Kategorie:cdampl|Medikation]]

Cdampl:Beispiel - Versionsgeschichte

Foemig: Initialfassung zur Kommentierung