Beispiel
(Teildokument von Einweisung (Muster 06))
Foemig (Diskussion | Beiträge) K (Draft) |
Foemig (Diskussion | Beiträge) K |
||
Zeile 74: | Zeile 74: | ||
<author> | <author> | ||
− | |||
− | |||
− | |||
<functionCode code="OA" displayName="Diensthabender Oberarzt" codeSystem="1.2.40.0.34.99.111.2.1" codeSystemName="Amadeus Spital - Funktionscodes"/> | <functionCode code="OA" displayName="Diensthabender Oberarzt" codeSystem="1.2.40.0.34.99.111.2.1" codeSystemName="Amadeus Spital - Funktionscodes"/> | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
<assignedAuthor> | <assignedAuthor> | ||
− | |||
− | |||
− | |||
<id root="1.2.40.0.34.99.111.1.3" extension="1111" assigningAuthorityName="Amadeus Spital"/> | <id root="1.2.40.0.34.99.111.1.3" extension="1111" assigningAuthorityName="Amadeus Spital"/> | ||
− | |||
− | |||
− | |||
− | |||
<code code="107" displayName="Fachärztin/Facharzt für Chirurgie" codeSystem="1.2.40.0.34.5.2" codeSystemName="gda-rollen"/> | <code code="107" displayName="Fachärztin/Facharzt für Chirurgie" codeSystem="1.2.40.0.34.5.2" codeSystemName="gda-rollen"/> | ||
− | |||
− | |||
− | |||
<telecom use="WP" value="tel:+43.6138.3453446.1111"/> | <telecom use="WP" value="tel:+43.6138.3453446.1111"/> | ||
− | |||
− | |||
− | |||
− | |||
<assignedPerson> | <assignedPerson> | ||
Zeile 112: | Zeile 89: | ||
<family>Stern</family> | <family>Stern</family> | ||
</name> | </name> | ||
− | |||
</assignedPerson> | </assignedPerson> | ||
− | |||
− | |||
− | |||
− | |||
<representedOrganization> | <representedOrganization> | ||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
− | |||
<name>Amadeus Spital - Chirurgische Abteilung</name> | <name>Amadeus Spital - Chirurgische Abteilung</name> | ||
− | |||
− | |||
− | |||
<telecom value="tel:+43.6138.3453446.0"/> | <telecom value="tel:+43.6138.3453446.0"/> | ||
<telecom value="fax:+43.6138.3453446.4674"/> | <telecom value="fax:+43.6138.3453446.4674"/> | ||
Zeile 139: | Zeile 100: | ||
<telecom value="http://www.amadeusspital.at"/> | <telecom value="http://www.amadeusspital.at"/> | ||
− | |||
− | |||
− | |||
<addr> | <addr> | ||
<streetName>Mozartgasse</streetName> | <streetName>Mozartgasse</streetName> | ||
Zeile 150: | Zeile 108: | ||
<country>Österreich</country> | <country>Österreich</country> | ||
</addr> | </addr> | ||
− | + | ||
</representedOrganization> | </representedOrganization> | ||
− | |||
</assignedAuthor> | </assignedAuthor> | ||
</author> | </author> | ||
− | |||
<custodian> | <custodian> | ||
Zeile 161: | Zeile 117: | ||
<representedCustodianOrganization> | <representedCustodianOrganization> | ||
− | |||
− | |||
− | |||
<id root="1.2.40.0.34.99.3" assigningAuthorityName="GDA Index"/> | <id root="1.2.40.0.34.99.3" assigningAuthorityName="GDA Index"/> | ||
− | |||
− | |||
− | |||
− | |||
<name>Amadeus Spital</name> | <name>Amadeus Spital</name> | ||
− | |||
− | |||
− | |||
− | |||
<telecom value="tel:+43.6138.3453446.0"/> | <telecom value="tel:+43.6138.3453446.0"/> | ||
− | |||
− | |||
− | |||
− | |||
<addr> | <addr> | ||
<streetName>Mozartgasse</streetName> | <streetName>Mozartgasse</streetName> | ||
Zeile 192: | Zeile 133: | ||
</custodian> | </custodian> | ||
− | |||
− | |||
− | |||
− | |||
− | |||
<participant typeCode="HLD"> | <participant typeCode="HLD"> | ||
<templateId root="1.2.40.0.34.11.1.1.6"/> | <templateId root="1.2.40.0.34.11.1.1.6"/> | ||
Zeile 236: | Zeile 172: | ||
<component> | <component> | ||
<structuredBody> | <structuredBody> | ||
+ | <component> | ||
+ | <section> | ||
+ | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.1"/> | ||
+ | <!-- ** Reason for Referral Section Template ** --> | ||
+ | <code | ||
+ | codeSystem="2.16.840.1.113883.6.1" | ||
+ | codeSystemName="LOINC" | ||
+ | code="42349-1" | ||
+ | displayName="REASON FOR REFERRAL"/> | ||
+ | <title>REASON FOR REFERRAL</title> | ||
+ | <!-- Unstructured text field --> | ||
+ | <text> | ||
+ | <paragraph>Follow up with Dr George Potomac for Asthma</paragraph> | ||
+ | </text> | ||
+ | </section> | ||
+ | </component> | ||
</structuredBody> | </structuredBody> | ||
− | |||
</component> | </component> | ||
</ClinicalDocument> | </ClinicalDocument> |
Version vom 14. März 2014, 13:59 Uhr
Dieses Material ist Teil des Leitfadens Einweisung (Muster 06).
|
vollständiges Beispiel
<?xml version="1.0" encoding="utf-8" standalone="yes"?>
<?xml-stylesheet type="text/xsl" href="vhitg-cda-v3.xsl"?>
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<realmCode code="DE"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="" assigningAuthorityName=""/>
<id root="" extension="" assigningAuthorityName=""/>
<code code="11490-0" displayName="Discharge summarization note (physician)" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Überweisung</title>
<effectiveTime value="20140207082015+0100"/>
<confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25" codeSystemName="HL7:Confidentiality"/>
<languageCode code="de-DE"/>
<setId root="1.2.40.0.34.99.111.1.1" extension="134F989" assigningAuthorityName="Amadeus Spital"/>
<versionNumber value="1"/>
<recordTarget>
<patientRole>
<!--
IDs des Patienten
-->
<!-- Identifikation des Patienten im lokalen System -->
<id root="" extension="" assigningAuthorityName=""/>
<!-- Identifikation des Patienten in der Affinity Domain -->
<id root="" extension="" assigningAuthorityName=""/>
<!--
Adresse des Patienten
-->
<addr use="H">
<streetAddressLine>Musterstraße 13a</streetAddressLine>
<postalCode>12345</postalCode>
<city>Musterstadt</city>
<country>Deutschland</country>
</addr>
<patient>
<!--
Name des Patienten
-->
<name>
<prefix qualifier="AC">Dipl.Ing.</prefix>
<prefix qualifier="NB">Hofrat</prefix>
<given>Herbert</given>
<given>Hannes</given>
<family>Mustermann</family>
<family qualifier="BR">VorDerHeirat</family>
<suffix qualifier="AC">BSc</suffix>
<suffix qualifier="AC">MBA</suffix>
</name>
<!--
Geburtsdatum des Patienten
-->
<birthTime value="19611224"/>
</patient>
</patientRole>
</recordTarget>
<author>
<functionCode code="OA" displayName="Diensthabender Oberarzt" codeSystem="1.2.40.0.34.99.111.2.1" codeSystemName="Amadeus Spital - Funktionscodes"/>
<assignedAuthor>
<id root="1.2.40.0.34.99.111.1.3" extension="1111" assigningAuthorityName="Amadeus Spital"/>
<code code="107" displayName="Fachärztin/Facharzt für Chirurgie" codeSystem="1.2.40.0.34.5.2" codeSystemName="gda-rollen"/>
<telecom use="WP" value="tel:+43.6138.3453446.1111"/>
<assignedPerson>
<!-- Name des Verfassers des Dokuments -->
<name>
<prefix>Dr.</prefix>
<given>Isabella</given>
<family>Stern</family>
</name>
</assignedPerson>
<representedOrganization>
<name>Amadeus Spital - Chirurgische Abteilung</name>
<telecom value="tel:+43.6138.3453446.0"/>
<telecom value="fax:+43.6138.3453446.4674"/>
<telecom value="mailto:info@amadeusspital.at"/>
<telecom value="http://www.amadeusspital.at"/>
<addr>
<streetName>Mozartgasse</streetName>
<houseNumber>1-7</houseNumber>
<postalCode>5350</postalCode>
<city>St.Wolfgang</city>
<state>Salzburg</state>
<country>Österreich</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="1.2.40.0.34.99.3" assigningAuthorityName="GDA Index"/>
<name>Amadeus Spital</name>
<telecom value="tel:+43.6138.3453446.0"/>
<addr>
<streetName>Mozartgasse</streetName>
<houseNumber>1-7</houseNumber>
<postalCode>5350</postalCode>
<city>St.Wolfgang</city>
<state>Salzburg</state>
<country>Österreich</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<participant typeCode="HLD">
<templateId root="1.2.40.0.34.11.1.1.6"/>
<!-- Versicherungszeitraum vom 01.01.2002 – 31.12.2013 -->
<time>
<low value="20020101"/>
<high value="20131231"/>
</time>
<associatedEntity classCode="POLHOLD">
<!-- Sozialversicherungsnummer des Patienten -->
<id root="1.2.40.0.10.1.4.3.1" extension="123424121961" assigningAuthorityName="Österreichische Sozialversicherung"/>
<!-- Code SELF (Patient ist selbst der Versicherungsnehmer) -->
<code code="SELF" displayName="self" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7:RoleCode"/>
<!-- Versicherungsgesellschaft -->
<scopingOrganization>
<name>Sozialversicherung der gew. Wirtschaft</name>
<telecom value="tel:01.54654.0"/>
<telecom value="fax:01.54654.385"/>
<telecom value="http://esv-sva.sozvers.at"/>
<addr>
<streetName>Wiedner Hauptstraße</streetName>
<houseNumber>84-86</houseNumber>
<postalCode>1051</postalCode>
<city>Wien</city>
<state>Wien</state>
<country>Österreich</country>
</addr>
</scopingOrganization>
</associatedEntity>
</participant>
<component>
<structuredBody>
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.1"/>
<!-- ** Reason for Referral Section Template ** -->
<code
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
code="42349-1"
displayName="REASON FOR REFERRAL"/>
<title>REASON FOR REFERRAL</title>
<!-- Unstructured text field -->
<text>
<paragraph>Follow up with Dr George Potomac for Asthma</paragraph>
</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>