1.2.276.0.76.10.4049/static-2015-03-03T000000: Unterschied zwischen den Versionen

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<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="border:1px solid #C0C0C0; width: 107pt; text-align: left;"><strong>Template </strong></th><td xmlns="" style="text-align: left; background-color: #F6F3EE">Problem Observation (Abschlussdiagnose)<i> / Problemobservationeddiagnosis</i></td></tr><tr><th style="text-align: left;">Id</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">1.2.276.0.76.10.4049</td></tr><tr><th style="text-align: left;">Klassifikation</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">CDA entry level template</td></tr><tr><th style="text-align: left;">Kontext</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4049</td></tr><tr><th style="text-align: left;"> Version </th><td xmlns="" style="text-align: left; background-color: #F6F3EE"> gültig ab 2015‑03‑03 Status In Entwicklung</td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Offen/Geschlossen</th><td xmlns="" style="background-color: #F6F3EE">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Beschreibung</th><td xmlns="">Beschwerden, Symptome, Diagnose, Probleme etc., hier: Abschlussdiagnose ggf. mit ICD10-Kode</td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Benutzt von / Benutzt</th><td xmlns="" style="vertical-align: top;" colspan="3"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td xmlns="" style="height: 30px;" colspan="2">Benutzt von / Benutzt 3 Templates</td></tr><tr><td xmlns="" colspan="2"><div><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="6" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Benutzt von Template-Id</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 xmlns="" style="text-align: left;">1.2.276.0.76.10.4048</td><td xmlns="" style="text-align: left;">Containment</td><td xmlns="" style="text-align: left;">Problemconcernacteddiagnoses <i xmlns="http://www.w3.org/1999/xhtml">Problem Concern Act (Abschlussdiagnosen)</i></td><td xmlns="" style="text-align: left;">2015‑03‑03</td></tr><tr><td xmlns="" style="text-align: left;">1.2.276.0.76.10.3055</td><td xmlns="" style="text-align: left;">[[Datei:Link.png|15px]]</td><td xmlns="" style="text-align: left;">Eddiagnosis <i xmlns="http://www.w3.org/1999/xhtml">Abschlussdiagnosen</i></td><td xmlns="" style="text-align: left;">2015‑01‑10</td></tr><tr><td xmlns="" style="text-align: left;">1.2.276.0.76.10.1015</td><td xmlns="" style="text-align: left;">[[Datei:Link.png|15px]]</td><td xmlns="" style="text-align: left;">EmergencymedicineNoteCDAdocument <i xmlns="http://www.w3.org/1999/xhtml">Emergency medicine Note CDA document</i></td><td xmlns="" style="text-align: left;">2014‑09‑18</td></tr></table></div></td></tr></table></td></tr><tr><th style="text-align: left;">Beziehung</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">Spezialisierung: Template 2.16.840.1.113883.10.12.303 (<i xmlns="http://www.w3.org/1999/xhtml">2005‑09‑07</i>)<br xmlns="http://www.w3.org/1999/xhtml" />Adaptation: Template 2.16.840.1.113883.10.20.22.4.4 (<i xmlns="http://www.w3.org/1999/xhtml">DYNAMIC</i>)</td></tr><tr class="explabel" style="vertical-align: top;"><td xmlns="">Beispiel</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">observation</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">OBS</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</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">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.4049</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><br /></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">8764b7c0-2111-43f2-a784-9a5fdfaa67f0</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><br /></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">282291009</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.96</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Diagnosis</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><br /></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="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#compl-1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><br /></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><br /></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="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20150304</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><br /></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">CE</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">/</span><span class="ppsign">&gt;</span><br /></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr><td xmlns="" colspan="2" class="tabtab"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="6" style="background: transparent;"><tr><th style="width: 1%; text-align: left;">Item</th><th style="width: 1%; text-align: left;">DT</th><th style="width: 1%; text-align: left;">Kard</th><th style="width: 1%; text-align: left;">Konf</th><th style="text-align: left;">Beschreibung</th><th style="width: 1%; text-align: left;">Label</th></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:observation<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml"></strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong></strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@classCode<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">OBS</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@moodCode<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">EVN</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@negationInd<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">0 .. 1</td><td xmlns=""> </td><td xmlns="" colspan="2"></td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">II</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong></strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@root<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">1.2.276.0.76.10.4049</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:id<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">II</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. *</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:code<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">CE</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@code<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">282291009</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">2.16.840.1.113883.6.96 (SNOMED Clinical Terms)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:text<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">ED</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>0 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong></strong></span></td><td xmlns="">Textform, enthält hier lediglich reference in den Text der Section</td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:reference<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">URL</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong></strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:statusCode<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">CS</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@code<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">completed</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:effectiveTime<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">IVL_TS</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns="">effectiveTime wird auch als "biologisch relevante Zeit" bezeichnet und ist der Zeitpunkt oder Zeitraum,                        für den die Beobachtung für den Patienten gilt.<br xmlns="http://www.w3.org/1999/xhtml" />                        Beispiel: Für Gesundheitsdienstleister, die einen Patienten heute in der Klinik sehen anamenstisch einen Herzinfarkt erheben,                          der vor fünf Jahren stattgefunden hat, ist effectiveTime: vor fünf Jahren.<br xmlns="http://www.w3.org/1999/xhtml" />                        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 werden kann, 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 xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:low<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">TS</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>R</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:high<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">TS</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>0 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>R</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:value<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">CE</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>R</strong></span></td><td xmlns="">ICD-10 Kode</td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td xmlns="" style="background-color: white"> </td><td xmlns="" class="conf">Constraint</td><td xmlns="" style="background-color: #FAFAD2" colspan="4">Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme (ICD), 10. Revision, German Modification, jeweils aktuelle Fassung</td></tr><tr><td xmlns="" style="background-color: white"> </td><td xmlns="" style="vertical-align: top;" class="conf">CONF </td><td xmlns="" colspan="4"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td xmlns="">muss aus der Konzeptdomäne "ICD10GM" gewählt werden</td></tr></table></td></tr><tr class="explabel" style="vertical-align: top;"><td xmlns="" style="background-color: white"> </td><td xmlns="">Beispiel</td><td xmlns="" colspan="4"><tt xmlns="http://www.w3.org/1999/xhtml"><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">CE</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">/</span><span class="ppsign">&gt;</span><br /></span></tt></td></tr></table></td></tr></table>
+
<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="border:1px solid #C0C0C0; width: 107pt; text-align: left;"><strong>Template </strong></th><td xmlns="" style="text-align: left; background-color: #F6F3EE">Problem Observation (Abschlussdiagnose)<i> / Problemobservationeddiagnosis</i></td></tr><tr><th style="text-align: left;">Id</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">1.2.276.0.76.10.4049</td></tr><tr><th style="text-align: left;">Klassifikation</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">CDA entry level template</td></tr><tr><th style="text-align: left;">Kontext</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4049</td></tr><tr><th style="text-align: left;"> Version </th><td xmlns="" style="text-align: left; background-color: #F6F3EE"> gültig ab 2015‑03‑03 Status In Entwicklung</td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Offen/Geschlossen</th><td xmlns="" style="background-color: #F6F3EE">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Beschreibung</th><td xmlns="">Beschwerden, Symptome, Diagnose, Probleme etc., hier: Abschlussdiagnose ggf. mit ICD10-Kode</td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Benutzt von / Benutzt</th><td xmlns="" style="vertical-align: top;" colspan="3"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td xmlns="" style="height: 30px;" colspan="2">Benutzt von / Benutzt 3 Templates</td></tr><tr><td xmlns="" colspan="2"><div><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="6" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Benutzt von Template-Id</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 xmlns="" style="text-align: left;">1.2.276.0.76.10.4048</td><td xmlns="" style="text-align: left;">Containment</td><td xmlns="" style="text-align: left;">Problemconcernacteddiagnoses <i xmlns="http://www.w3.org/1999/xhtml">Problem Concern Act (Abschlussdiagnosen)</i></td><td xmlns="" style="text-align: left;">2015‑03‑03</td></tr><tr><td xmlns="" style="text-align: left;">1.2.276.0.76.10.3055</td><td xmlns="" style="text-align: left;">[[Datei:Link.png|15px]]</td><td xmlns="" style="text-align: left;">Eddiagnosis <i xmlns="http://www.w3.org/1999/xhtml">Abschlussdiagnosen</i></td><td xmlns="" style="text-align: left;">2015‑01‑10</td></tr><tr><td xmlns="" style="text-align: left;">1.2.276.0.76.10.1015</td><td xmlns="" style="text-align: left;">[[Datei:Link.png|15px]]</td><td xmlns="" style="text-align: left;">EmergencymedicineNoteCDAdocument <i xmlns="http://www.w3.org/1999/xhtml">Emergency medicine Note CDA document</i></td><td xmlns="" style="text-align: left;">2014‑09‑18</td></tr></table></div></td></tr></table></td></tr><tr><th style="text-align: left;">Beziehung</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">Spezialisierung: Template 2.16.840.1.113883.10.12.303 (<i xmlns="http://www.w3.org/1999/xhtml">2005‑09‑07</i>)<br xmlns="http://www.w3.org/1999/xhtml" />Adaptation: Template 2.16.840.1.113883.10.20.22.4.4 (<i xmlns="http://www.w3.org/1999/xhtml">DYNAMIC</i>)</td></tr><tr class="explabel" style="vertical-align: top;"><td xmlns="">Beispiel</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">observation</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">OBS</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</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">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.4049</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><br /></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">1.2.276.0.76.4.17.9814184919</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">8764b7c0-2111-43f2-a784-9a5fdfaa67f0</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><br /></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">282291009</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.96</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Diagnosis</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><br /></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="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#compl-1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><br /></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><br /></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="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20150304</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><br /></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">CE</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">/</span><span class="ppsign">&gt;</span><br /></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr><td xmlns="" colspan="2" class="tabtab"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="6" style="background: transparent;"><tr><th style="width: 1%; text-align: left;">Item</th><th style="width: 1%; text-align: left;">DT</th><th style="width: 1%; text-align: left;">Kard</th><th style="width: 1%; text-align: left;">Konf</th><th style="text-align: left;">Beschreibung</th><th style="width: 1%; text-align: left;">Label</th></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:observation<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml"></strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong></strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@classCode<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">OBS</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@moodCode<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">EVN</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@negationInd<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">0 .. 1</td><td xmlns=""> </td><td xmlns="" colspan="2"></td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">II</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong></strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@root<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">1.2.276.0.76.10.4049</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:id<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">II</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. *</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:code<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">CE</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@code<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">282291009</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">2.16.840.1.113883.6.96 (SNOMED Clinical Terms)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:text<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">ED</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>0 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong></strong></span></td><td xmlns="">Textform, enthält hier lediglich reference in den Text der Section</td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:reference<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">URL</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong></strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:statusCode<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">CS</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@code<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">completed</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:effectiveTime<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">IVL_TS</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns="">effectiveTime wird auch als "biologisch relevante Zeit" bezeichnet und ist der Zeitpunkt oder Zeitraum,                        für den die Beobachtung für den Patienten gilt.<br xmlns="http://www.w3.org/1999/xhtml" />                        Beispiel: Für Gesundheitsdienstleister, die einen Patienten heute in der Klinik sehen anamenstisch einen Herzinfarkt erheben,                          der vor fünf Jahren stattgefunden hat, ist effectiveTime: vor fünf Jahren.<br xmlns="http://www.w3.org/1999/xhtml" />                        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 werden kann, 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 xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:low<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">TS</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>R</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:high<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">TS</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>0 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>R</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:value<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">CE</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>R</strong></span></td><td xmlns="">ICD-10 Kode</td><td xmlns="" style="background-color: #FFEEEE">(Problemobservationeddiagnosis)</td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td xmlns="" style="background-color: white"> </td><td xmlns="" class="conf">Constraint</td><td xmlns="" style="background-color: #FAFAD2" colspan="4">Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme (ICD), 10. Revision, German Modification, jeweils aktuelle Fassung</td></tr><tr><td xmlns="" style="background-color: white"> </td><td xmlns="" style="vertical-align: top;" class="conf">CONF </td><td xmlns="" colspan="4"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td xmlns="">muss aus der Konzeptdomäne "ICD10GM" gewählt werden</td></tr></table></td></tr><tr class="explabel" style="vertical-align: top;"><td xmlns="" style="background-color: white"> </td><td xmlns="">Beispiel</td><td xmlns="" colspan="4"><tt xmlns="http://www.w3.org/1999/xhtml"><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">CE</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">/</span><span class="ppsign">&gt;</span><br /></span></tt></td></tr></table></td></tr></table>

Version vom 2. Juni 2015, 15:27 Uhr

Template Problem Observation (Abschlussdiagnose) / Problemobservationeddiagnosis
Id1.2.276.0.76.10.4049
KlassifikationCDA entry level template
KontextElternknoten des Template-Element mit Id 1.2.276.0.76.10.4049
Version gültig ab 2015‑03‑03 Status In Entwicklung
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
BeschreibungBeschwerden, Symptome, Diagnose, Probleme etc., hier: Abschlussdiagnose ggf. mit ICD10-Kode
Benutzt von / Benutzt
Benutzt von / Benutzt 3 Templates
Benutzt von Template-Id als NameVersion
1.2.276.0.76.10.4048ContainmentProblemconcernacteddiagnoses Problem Concern Act (Abschlussdiagnosen)2015‑03‑03
1.2.276.0.76.10.3055Link.pngEddiagnosis Abschlussdiagnosen2015‑01‑10
1.2.276.0.76.10.1015Link.pngEmergencymedicineNoteCDAdocument Emergency medicine Note CDA document2014‑09‑18
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Adaptation: Template 2.16.840.1.113883.10.20.22.4.4 (DYNAMIC)
Beispiel<observation classCode="OBS" moodCode="EVN">
  <templateId root="1.2.276.0.76.10.4049"/>
  <id root="1.2.276.0.76.4.17.9814184919" extension="8764b7c0-2111-43f2-a784-9a5fdfaa67f0"/>
  <code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>
  <text>
    <reference value="#compl-1"/>
  </text>
  <statusCode code="completed"/>
  <effectiveTime>
    <low value="20150304"/>
  </effectiveTime>
  <value xsi:type="CE" code="A05.1" codeSystem="1.2.276.0.76.5.413" displayName="Botulismus"/>
</observation>
ItemDTKardKonfBeschreibungLabel
hl7:observation
1 .. 1(Problemobservationeddiagnosis)
Treetree.png@classCode
1 .. 1FOBS
Treetree.png@moodCode
1 .. 1FEVN
Treetree.png@negationInd
0 .. 1 
Treetree.pnghl7:templateId
II1 .. 1(Problemobservationeddiagnosis)
Treeblank.pngTreetree.png@root
1 .. 1F1.2.276.0.76.10.4049
Treetree.pnghl7:id
II1 .. *M(Problemobservationeddiagnosis)
Treetree.pnghl7:code
CE1 .. 1M(Problemobservationeddiagnosis)
Treeblank.pngTreetree.png@code
1 .. 1F282291009
Treeblank.pngTreetree.png@codeSystem
1 .. 1F2.16.840.1.113883.6.96 (SNOMED Clinical Terms)
Treetree.pnghl7:text
ED0 .. 1Textform, enthält hier lediglich reference in den Text der Section(Problemobservationeddiagnosis)
Treeblank.pngTreetree.pnghl7:reference
URL1 .. 1(Problemobservationeddiagnosis)
Treetree.pnghl7:statusCode
CS1 .. 1M(Problemobservationeddiagnosis)
Treeblank.pngTreetree.png@code
1 .. 1Fcompleted
Treetree.pnghl7:effectiveTime
IVL_TS1 .. 1MeffectiveTime 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 anamenstisch 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 werden kann, 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.
(Problemobservationeddiagnosis)
Treeblank.pngTreetree.pnghl7:low
TS1 .. 1R(Problemobservationeddiagnosis)
Treeblank.pngTreetree.pnghl7:high
TS0 .. 1R(Problemobservationeddiagnosis)
Treetree.pnghl7:value
CE1 .. 1RICD-10 Kode(Problemobservationeddiagnosis)
 ConstraintInternationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme (ICD), 10. Revision, German Modification, jeweils aktuelle Fassung
 CONF
muss aus der Konzeptdomäne "ICD10GM" gewählt werden
 Beispiel<value xsi:type="CE" code="A05.1" codeSystem="1.2.276.0.76.5.413" displayName="Botulismus"/>