Document Reference Entry (Template)

Aus Hl7wiki
(Teildokument von CDA für die elektronische Fallakte)
Wechseln zu: Navigation, Suche
K (→‎Example)
K (hat „cdaefa:Document Reference (Entry)“ nach „cdaefa:Document Reference Entry (Template)“ verschoben: Harmonisierung Namensgebung)
 
(8 dazwischenliegende Versionen von 2 Benutzern werden nicht angezeigt)
Zeile 1: Zeile 1:
 
{{DocumentPart}}
 
{{DocumentPart}}
 +
 +
=Entry: Consent Directive Observation (Entry)=
 +
 +
{| class="hl7table"
 +
|bgcolor="ddddff"|Template ID|| colspan=2 | 1.2.276.0.76.3.1.81.81.6.4.4
 +
|-
 +
|bgcolor="ddddff"| General Description|| colspan=2 | Hiermit wird auf Entry-Level die Übermittlung von Referenzen auf Dokumente definiert.
 +
|-
 +
|bgcolor="ddddff"|LOINC Code||bgcolor="ddddff"|Opt.||bgcolor="ddddff"|Description
 +
|-
 +
| ???? || O ||
 +
|}
  
 
A Document Reference Entry refers to a single information object (e.g. within an eCR or another type of health record).  
 
A Document Reference Entry refers to a single information object (e.g. within an eCR or another type of health record).  
Zeile 30: Zeile 42:
 
</syntaxhighlight>
 
</syntaxhighlight>
  
 +
{| class="hl7table"
 +
! Lvl
 +
! RIM
 +
! Name
 +
! Desc
 +
! DT
 +
! Kard
 +
! Conf
 +
! Beschreibung
 +
 +
|-
 +
|1
 +
|bgcolor="ff8888"|act
 +
|entry
 +
|
 +
|
 +
|
 +
|
 +
 +
|-
 +
|2
 +
|bgcolor="ff8888"|act
 +
|act
 +
|
 +
|
 +
|
 +
|
 +
 +
|-
 +
|3
 +
|bgcolor="ff8888"|act
 +
|
 +
|
 +
|
 +
|
 +
|
 
;<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/><br><templateId root='1.2.276.0.76.3.1.81.81.6.4.4'/>
 
;<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/><br><templateId root='1.2.276.0.76.3.1.81.81.6.4.4'/>
 
:The <templateId> elements shown above MUST be present, and indicated that this is an eCR Document Reference entry that implements an [http://wiki.ihe.net/index.php?title=External_References IHE PCC External Document] entry.
 
:The <templateId> elements shown above MUST be present, and indicated that this is an eCR Document Reference entry that implements an [http://wiki.ihe.net/index.php?title=External_References IHE PCC External Document] entry.
 +
 +
|-
 +
|3
 +
|bgcolor="ff8888"|act
 +
|
 +
|
 +
|
 +
|
 +
|
  
 
;<id root='' extension=''/>
 
;<id root='' extension=''/>
 
:The object reference is an entity on its own and therefore needs an identifier that MUST NOT be the identifier of the object itself.     
 
:The object reference is an entity on its own and therefore needs an identifier that MUST NOT be the identifier of the object itself.     
  
 +
|-
 +
|3
 +
|bgcolor="ff8888"|act
 +
|
 +
|
 +
|
 +
|
 +
|
 
;<text><reference value='#...'/></text>
 
;<text><reference value='#...'/></text>
 
:SHOULD contain a reference to the narrative description of the document that is provided in the section’s <text> element. Alternatively the description of the document MAY be directly given within this element.  
 
:SHOULD contain a reference to the narrative description of the document that is provided in the section’s <text> element. Alternatively the description of the document MAY be directly given within this element.  
  
 +
|-
 +
|3
 +
|bgcolor="ff8888"|act
 +
|
 +
|
 +
|
 +
|
 +
|
 
;<effectiveTime value='YYYYMMDD'/>
 
;<effectiveTime value='YYYYMMDD'/>
 
:This element holds the <effectiveTime> value as given in the CDA header of the referenced document.  
 
:This element holds the <effectiveTime> value as given in the CDA header of the referenced document.  
  
 +
|-
 +
|3
 +
|bgcolor="ff8888"|act
 +
|
 +
|
 +
|
 +
|
 +
|
 
;<externalDocument ....><br>&nbsp;&nbsp;&nbsp;&lt;code code="..." codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="..."/>
 
;<externalDocument ....><br>&nbsp;&nbsp;&nbsp;&lt;code code="..." codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="..."/>
 
:If known, this element MUST record the LOINC code of the document. If the LOINC code of the document is not known a NullFlavor of ‘UNK’ MUST be set.
 
:If known, this element MUST record the LOINC code of the document. If the LOINC code of the document is not known a NullFlavor of ‘UNK’ MUST be set.
  
 +
|-
 +
|3
 +
|bgcolor="ff8888"|act
 +
|
 +
|
 +
|
 +
|
 +
|
 
;<externalDocument ....><br>&nbsp;&nbsp;&nbsp;...<br>&nbsp;&nbsp;&nbsp;<id root='' extension=''/>
 
;<externalDocument ....><br>&nbsp;&nbsp;&nbsp;...<br>&nbsp;&nbsp;&nbsp;<id root='' extension=''/>
 
:This element MUST record an identifier that can be used to retrieve the document from a Document Repository.
 
:This element MUST record an identifier that can be used to retrieve the document from a Document Repository.
  
 +
|-
 +
|3
 +
|bgcolor="ff8888"|act
 +
|
 +
|
 +
|
 +
|
 +
|
 
;<externalDocument ....><br>&nbsp;&nbsp;&nbsp;...<br>&nbsp;&nbsp;&nbsp;<text mediaType='mime-type'>&lt;reference value='&#104;ttps&#58;//....'/></text>
 
;<externalDocument ....><br>&nbsp;&nbsp;&nbsp;...<br>&nbsp;&nbsp;&nbsp;<text mediaType='mime-type'>&lt;reference value='&#104;ttps&#58;//....'/></text>
 
:The MIME-Type of the external document MUST be given in the @mediaType-attribute of the <text> element. A reference value MAY be provided to record additional information that is needed by the document managing system to retrive the document. If given, the reference value MUST be coded as an URL. If no additional information is provided, the reference MUST be nullified with a nullFlavor of “NI”.
 
:The MIME-Type of the external document MUST be given in the @mediaType-attribute of the <text> element. A reference value MAY be provided to record additional information that is needed by the document managing system to retrive the document. If given, the reference value MUST be coded as an URL. If no additional information is provided, the reference MUST be nullified with a nullFlavor of “NI”.
 
:For fetching the external  document, the content of the URL together with the external document identifier MUST be sent to the connected storage as provided. Therefore this information MUST be sufficient for the document store to discover and provide the document.
 
:For fetching the external  document, the content of the URL together with the external document identifier MUST be sent to the connected storage as provided. Therefore this information MUST be sufficient for the document store to discover and provide the document.
 +
 +
|}
  
 
== Example ==
 
== Example ==
Zeile 62: Zeile 161:
 
         <id root='..' extension='..'/>
 
         <id root='..' extension='..'/>
 
      
 
      
−
         &lt;code nullFlavor='NA' />
+
         <code nullFlavor='NA' />
 
      
 
      
 
         <text><reference value='#doc159382919223'/></text>
 
         <text><reference value='#doc159382919223'/></text>
Zeile 68: Zeile 167:
 
         <reference typeCode='REFR'>
 
         <reference typeCode='REFR'>
 
             <externalDocument classCode='DOC' moodCode='EVN'>
 
             <externalDocument classCode='DOC' moodCode='EVN'>
−
               &lt;code code="11522-0" codeSystem="2.16.840.1.113883.6.1"
+
               <id root='...'/>
 +
              <code code="11522-0" codeSystem="2.16.840.1.113883.6.1"
 
                         codeSystemName="LOINC" displayName="Radiology report"/>
 
                         codeSystemName="LOINC" displayName="Radiology report"/>
−
              <id root='...'/>
 
 
               <text mediaType='mime-type'><reference value=
 
               <text mediaType='mime-type'><reference value=
 
                     'http://ecrDocRep.ecrProvider.de?node=cluster4'/></text>
 
                     'http://ecrDocRep.ecrProvider.de?node=cluster4'/></text>
Zeile 78: Zeile 177:
 
   </entry>
 
   </entry>
 
</syntaxhighlight>
 
</syntaxhighlight>
 +
 +
 +
[[Kategorie:CDA Entry Level Template|Document Reference (Entry)]]

Aktuelle Version vom 8. Februar 2013, 15:43 Uhr

Dieses Material ist Teil des Leitfadens CDA für die elektronische Fallakte.
  • Direkt im Wiki geändert werden sollten Schreibfehler, ergänzende Hinweise.
  • Offene Fragen, die der Diskussionen bedürfen, sollten auf der Diskussionsseite aufgenommen werden.
  • Liste der Seiten dieses Leitfadens: hier, Liste der Seiten, in denen dieses Material verwendet (transkludiert) siehe hier .

Entry: Consent Directive Observation (Entry)

Template ID 1.2.276.0.76.3.1.81.81.6.4.4
General Description Hiermit wird auf Entry-Level die Übermittlung von Referenzen auf Dokumente definiert.
LOINC Code Opt. Description
???? O

A Document Reference Entry refers to a single information object (e.g. within an eCR or another type of health record).

Standards

Template

   <entry>
      <act classCode='ACT' moodCode='EVN'> 
         <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
         <templateId root='1.2.276.0.76.3.1.81.81.6.4.4'/>
         <id root='' extension=''/>
         <code nullFlavor='NA' />
         <text><reference value='#...'/></text>
         <effectiveTime value='YYYYMMDD'/>
         <reference typeCode='REFR'>
            <externalDocument classCode='DOC' moodCode='EVN'>
               <!-- required if known classification of the document -->
               <code code="..." codeSystem="2.16.840.1.113883.6.1"
                       codeSystemName="LOINC" displayName="..."/>
               <id extension='' root=''/>
               <text mediaType='mime-type'><reference value='&#104;ttp://....'></text>
            </externalDocument>
         </reference>
      </act>
   </entry>
Lvl RIM Name Desc DT Kard Conf Beschreibung
1 act entry
2 act act
3 act
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
<templateId root='1.2.276.0.76.3.1.81.81.6.4.4'/>
The <templateId> elements shown above MUST be present, and indicated that this is an eCR Document Reference entry that implements an IHE PCC External Document entry.
3 act
<id root= extension=/>
The object reference is an entity on its own and therefore needs an identifier that MUST NOT be the identifier of the object itself.
3 act
<text><reference value='#...'/></text>
SHOULD contain a reference to the narrative description of the document that is provided in the section’s <text> element. Alternatively the description of the document MAY be directly given within this element.
3 act
<effectiveTime value='YYYYMMDD'/>
This element holds the <effectiveTime> value as given in the CDA header of the referenced document.
3 act
<externalDocument ....>
   <code code="..." codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="..."/>
If known, this element MUST record the LOINC code of the document. If the LOINC code of the document is not known a NullFlavor of ‘UNK’ MUST be set.
3 act
<externalDocument ....>
   ...
   <id root= extension=/>
This element MUST record an identifier that can be used to retrieve the document from a Document Repository.
3 act
<externalDocument ....>
   ...
   <text mediaType='mime-type'><reference value='https://....'/></text>
The MIME-Type of the external document MUST be given in the @mediaType-attribute of the <text> element. A reference value MAY be provided to record additional information that is needed by the document managing system to retrive the document. If given, the reference value MUST be coded as an URL. If no additional information is provided, the reference MUST be nullified with a nullFlavor of “NI”.
For fetching the external document, the content of the URL together with the external document identifier MUST be sent to the connected storage as provided. Therefore this information MUST be sufficient for the document store to discover and provide the document.

Example

   <entry>
      <act classCode='ACT' moodCode='EVN'> 
         <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4'/>
         <templateId root='1.2.276.0.76.3.1.81.81.6.4.4'/>
    
         <id root='..' extension='..'/>
    
         <code nullFlavor='NA' />
    
         <text><reference value='#doc159382919223'/></text>
    
         <reference typeCode='REFR'>
            <externalDocument classCode='DOC' moodCode='EVN'>
               <id root='...'/>
               <code code="11522-0" codeSystem="2.16.840.1.113883.6.1"
                        codeSystemName="LOINC" displayName="Radiology report"/>
               <text mediaType='mime-type'><reference value=
                     'http://ecrDocRep.ecrProvider.de?node=cluster4'/></text>
            </externalDocument>
         </reference>
      </act>
   </entry>
Abgerufen von „https://wiki.hl7.de/index.php?title=cdaefa:Document_Reference_Entry_(Template)&oldid=10974“