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| − | <table class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="border:1px solid #C0C0C0; width: 107pt;" align="left"><strong>Template (intern)</strong></th><td align="left" style="background-color: #F6F3EE">Erhobene Befunde<i> / Hospitaldischargestudiessummarysection</i></td></tr><tr><th align="left">Id</th><td align="left" style="background-color: #F6F3EE">1.2.276.0.76.10.3025</td></tr><tr><th align="left">Klassifikation</th><td align="left" style="background-color: #F6F3EE">CDA section level template</td></tr><tr><th align="left"> Version </th><td align="left" style="background-color: #F6F3EE"> gültig ab 2013‑12‑30 Status In Entwicklung</td></tr><tr valign="top"><th align="left">Offen/Geschlossen</th><td style="background-color: #F6F3EE">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr valign="top"><th align="left">Beschreibung</th><td>Erhobene Befunde</td></tr><tr valign="top"><th align="left">Benutzt von / Benutzt</th><td valign="top" colspan="3"><table class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td class="toggler" colspan="2" height="30px">Benutzt von / Benutzt 2 Templates</td></tr><tr><td colspan="2"><div class="toggle"><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="6" style="background: transparent;"><tr><th width="20%" align="left">Benutzt von Template-Id</th><th width="60%" align="left">Name</th><th width="20%" align="left">Version</th></tr><tr><td align="left">1.2.276.0.76.10.1013</td><td align="left"><i>Arztbrief</i></td><td align="left">2014‑08‑25</td></tr><tr><td align="left">1.2.276.0.76.10.1013</td><td align="left"><i>Arztbrief</i></td><td align="left">2013‑12‑30</td></tr></table></div></td></tr></table></td></tr><tr class="explabel" valign="top"><td>Beispiel</td><td class="explabelblue"><tt><div><span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">></span><div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.3025</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">11493-4</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="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">></span><span class="pptext">Erhobene Befunde</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">></span></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">></span><div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">list</span><span class="ppsign">></span><div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span><span class="pptext">Pulmo: Basal diskrete RGs</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span><span class="pptext">Cor: oB</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span><span class="pptext">Abdomen: weich, Peristaltik: +++</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span><span class="pptext">Muskulatur: atrophisch</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span><span class="pptext">Mundhöhle: Soor, Haarleukoplakie</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span><span class="pptext">Haut blass, seborrhoisches Ekzem, Schleimhäute blass, Hautturgor herabgesetzt</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span><span class="pptext">Neuro: herabgesetztes Vibrationsempfinden der Beine, distal betont, Parästesien der Beine, PSR, AST oB und seitengleich.</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">item</span><span class="ppsign">></span></div> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">list</span><span class="ppsign">></span></div> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">></span></div><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">></span></div></tt></td></tr><tr><td colspan="2" class="tabtab"><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="6" style="background: transparent;"><tr><th align="left" width="1%">Item</th><th align="left" width="1%">DT</th><th align="left" width="1%">Card</th><th align="left" width="1%">Conf</th><th align="left">Desc</th><th align="left" width="1%">Label</th></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:section<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong></strong></td><td style="vertical-align: top;"><span style="color: black;"><strong></strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE">(Hospitaldischargestudiessummarysection)</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:templateId<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>II</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1 .. 1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE">(Hospitaldischargestudiessummarysection)</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>root<br></strong></tt></td></tr></table></td><td></td><td>1 .. 1</td><td>F</td><td colspan="2">1.2.276.0.76.10.3025</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:code<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>CE</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1 .. 1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(Hospitaldischargestudiessummarysection)</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>code<br></strong></tt></td></tr></table></td><td></td><td>1 .. 1</td><td>F</td><td colspan="2">11493-4</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>codeSystem<br></strong></tt></td></tr></table></td><td></td><td>1 .. 1</td><td>F</td><td colspan="2">2.16.840.1.113883.6.1 (LOINC)</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:title<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>ST</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1 .. 1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(Hospitaldischargestudiessummarysection)</td></tr><tr bgcolor="#FFEEEE" valign="top"><td style="background-color: white"></td><td class="conf" valign="top">CONF </td><td colspan="4" style="background-color: white"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr valign="top"><td>Elementinhalt muss "Erhobene Befunde" sein</td></tr></table></td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:text<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>SD.TEXT</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1 .. 1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(Hospitaldischargestudiessummarysection)</td></tr></table></td></tr></table>
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