2.16.840.1.113883.2.6.60.6.10.4/static-2014-05-13T193126: Unterschied zwischen den Versionen

Version vom 28. Dezember 2015, 21:46 Uhr

Template Diagnostic Conclusion Section / DiagnosticConclusionSection

Id 2.16.840.1.113883.2.6.60.6.10.4

Version gültig ab 2014‑05‑13 19:31:26 Status In Entwicklung

Klassifikation CDA Section level template

Kontext Elternknoten des Template-Element mit Id 2.16.840.1.113883.2.6.60.6.10.4

Offen/Geschlossen Offen (auch andere als die definierten Elemente sind erlaubt)

Beschreibung

The Diagnostic Conclusion section contains diagnoses on all specimens that are delivered to the pathology department from one operation or patient visit to a single clinician on a particular day. The diagnoses for each specimen or group of specimens are reported separately. This section includes additional pathologic finding(s) and the results of ancillary study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.

Assoziiert mit

Assoziiert mit 1 Konzept

Id	Name	Datensatz
psr-dataelement-3		PSR

Benutzt von / Benutzt

Benutzt von / Benutzt 7 Templates

Benutzt von Template-Id	als	Name	Version
2.16.840.1.113883.2.6.60.6.10.1	Containment	PathologyStructuredReport Pathology Structured Report	2014‑05‑13 11:57:57
Benutzt Template-Id	als	Name	Version
1.2.276.0.76.10.90025	Containment	CDAAuthorBody	DYNAMIC
2.16.840.1.113883.2.6.60.6.10.34	Containment	ProblemOrganizer	DYNAMIC

Beziehung Spezialisierung: Template 2.16.840.1.113883.10.12.201 (2005‑09‑07)

Beispiel <section classCode="DOCSECT" moodCode="EVN"> <templateId root="2.16.840.1.113883.2.6.60.6.10.4"/> <id root="1.2.3.999" extension="--example only--"/> <code code="22637-3" codeSystem="2.16.840.1.113883.6.1" displayName="'Pathology report diagnosis"/> <title>Diagnostic conclusion</title> <text/> <author>  </author> <entry>  </entry></section>

Item DT Kard Konf Beschreibung Label

hl7:section

1 .. 1

M

(DiagnosticConclusionSection)

@classCode

0 .. 1

F

DOCSECT

@moodCode

0 .. 1

F

EVN

Ziel der Konzept Id(s):

psr-dataelement-3

hl7:templateId

II

1 .. 1

R

(DiagnosticConclusionSection)

@root

1 .. 1

F

2.16.840.1.113883.2.6.60.6.10.4

hl7:id

II

0 .. 1

(DiagnosticConclusionSection)

hl7:code

CE

0 .. 1

(DiagnosticConclusionSection)

@code

1 .. 1

F

22637-3

@codeSystem

1 .. 1

F

2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)

@displayName

1 .. 1

F

'Pathology report diagnosis

@codeSystemName

1 .. 1

F

LOINC

hl7:title

ST

1 .. 1

M

(DiagnosticConclusionSection)

CONF

Elementinhalt muss "Diagnostic conclusion" sein

hl7:text

SD.TEXT

1 .. 1

M

(DiagnosticConclusionSection)

Beispiel

Diagnosis

<text> Invasive breast cancer, no special type TNM: pT1c pN0(0/3sn) L0 V0 R0 G2 ICD-O-3: 8500/3 </text>

hl7:author

0 .. *

(DiagnosticConclusionSection)

Beinhaltet 1.2.276.0.76.10.90025 CDA Author (Body) (DYNAMIC)

hl7:entry

1 .. *

R

(DiagnosticConclusionSection)

Beinhaltet 2.16.840.1.113883.2.6.60.6.10.34 Problem Organizer (DYNAMIC)

@@ Zeile 4: / Zeile 4: @@
            study(ies) and may include diagrams and still images or virtual slides, if taken. In case of cancer, this section includes the cancer checklist.</span>
                      </p>
-                 </td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Assoziiert mit</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">Assoziiert mit 1 Konzept</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="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Id</th><th style="width: 60%; text-align: left;">Name</th><th style="width: 20%; text-align: left;">Datensatz</th></tr><tr><td xmlns="" style="text-align: left; vertical-align: top; width: 1%;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">psr-data&#8203;element-</span>3</td><td xmlns="" style="text-align: left; vertical-align: top;"></td><td xmlns="" style="text-align: left; vertical-align: top;">PSR</td></tr></table></div></td></tr></table></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 6 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="3" 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;">2.16.840.1.113883.2.6.60.6.10.1</td><td xmlns="" style="text-align: left;">Containment</td><td xmlns="" style="text-align: left;">PathologyStructuredReport <i xmlns="http://www.w3.org/1999/xhtml">Pathology Structured Report</i></td><td xmlns="" style="text-align: left;">2014‑05‑13 11:57:57</td></tr><tr><th style="width: 20%; text-align: left;">Benutzt 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;">1.2.276.0.76.10.90025</td><td xmlns="" style="text-align: left;">Containment</td><td xmlns="" style="text-align: left;">CDAAuthorBody <i xmlns="http://www.w3.org/1999/xhtml"></i></td><td xmlns="" style="text-align: left;">DYNAMIC</td></tr><tr><td xmlns="" style="text-align: left;">2.16.840.1.113883.2.6.60.6.10.34</td><td xmlns="" style="text-align: left;">Containment</td><td xmlns="" style="text-align: left;">ProblemOrganizer <i xmlns="http://www.w3.org/1999/xhtml"></i></td><td xmlns="" style="text-align: left;">DYNAMIC</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 2.16.840.1.113883.10.12.201 (<i xmlns="http://www.w3.org/1999/xhtml">2005‑09‑07</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">section</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">DOCSECT</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">2.16.840.1.113883.2.6.60.6.10.4</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">1.2.3.999</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">--example only--</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">22637-3</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">displayName</span><span class="ppsign">="</span><span class="ppcontent">'Pathology report 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">title</span><span class="ppsign">&gt;</span><span class="pptext">Diagnostic conclusion</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</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">author</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template CDAAuthorBody (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">author</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entry</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 2.16.840.1.113883.2.6.60.6.10.9 (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entry</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</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:section<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>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(DiagnosticConclusionSection)</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|16px]]</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="">0 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">DOCSECT</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|16px]]</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="">0 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">EVN</td></tr><tr><td xmlns="" style="background-color: white"> </td><td xmlns="" style="vertical-align: top; text-align: left;">[[Datei:Target.png|16px]]</td><td xmlns="" colspan="4" style="background-color: #F4FFF4" class="tabtab">Ziel der Konzept Id(s): <table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="background-color: #F4FFF4"><td xmlns="" style="width: 25%; vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">psr-data&#8203;element-</span>3</td><td xmlns="" style="vertical-align: top;"></td></tr></table></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|16px]]</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>R</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(DiagnosticConclusionSection)</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</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">2.16.840.1.113883.2.6.60.6.10.4</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|16px]]</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>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=""></td><td xmlns="" style="background-color: #FFEEEE">(DiagnosticConclusionSection)</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|16px]]</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>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=""></td><td xmlns="" style="background-color: #FFEEEE">(DiagnosticConclusionSection)</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</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">22637-3</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</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">2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@displayName<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">'Pathology report diagnosis</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@codeSystemName<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">LOINC</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|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:title<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">ST</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">(DiagnosticConclusionSection)</td></tr><tr style="vertical-align: top; background-color: #FFEEEE;"><td xmlns="" style="background-color: white"> </td><td xmlns="" style="vertical-align: top;" class="conf">CONF </td><td xmlns="" colspan="4" style="background-color: white"><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="">Elementinhalt muss "Diagnostic conclusion" sein</td></tr></table></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|16px]]</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">SD.TEXT</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">(DiagnosticConclusionSection)</td></tr><tr class="explabel" style="vertical-align: top;"><td xmlns="" style="background-color: white"> </td><td xmlns="">Beispiel</td><td xmlns="" colspan="4"><div>Diagnosis</div><tt xmlns="http://www.w3.org/1999/xhtml"><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><span class="pptext"> Invasive breast cancer, no special type TNM: pT1c pN0(0/3sn) L0 V0 R0 G2 ICD-O-3: 8500/3 </span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span></tt></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|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:author<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>0 .. *</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">(DiagnosticConclusionSection)</td></tr><tr style="vertical-align: top; background-color: #FFEEEE;"><td xmlns="" style="background-color: white"> </td><td xmlns="" style="background-color: #FFEEEE">Beinhaltet</td><td xmlns="" style="background-color: #FFEEAA" colspan="3">
+                 </td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Assoziiert mit</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">Assoziiert mit 1 Konzept</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="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Id</th><th style="width: 60%; text-align: left;">Name</th><th style="width: 20%; text-align: left;">Datensatz</th></tr><tr><td xmlns="" style="text-align: left; vertical-align: top; width: 1%;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">psr-data&#8203;element-</span>3</td><td xmlns="" style="text-align: left; vertical-align: top;"></td><td xmlns="" style="text-align: left; vertical-align: top;">PSR</td></tr></table></div></td></tr></table></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 7 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="3" 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;">2.16.840.1.113883.2.6.60.6.10.1</td><td xmlns="" style="text-align: left;">Containment</td><td xmlns="" style="text-align: left;">PathologyStructuredReport <i xmlns="http://www.w3.org/1999/xhtml">Pathology Structured Report</i></td><td xmlns="" style="text-align: left;">2014‑05‑13 11:57:57</td></tr><tr><th style="width: 20%; text-align: left;">Benutzt 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;">1.2.276.0.76.10.90025</td><td xmlns="" style="text-align: left;">Containment</td><td xmlns="" style="text-align: left;">CDAAuthorBody <i xmlns="http://www.w3.org/1999/xhtml"></i></td><td xmlns="" style="text-align: left;">DYNAMIC</td></tr><tr><td xmlns="" style="text-align: left;">2.16.840.1.113883.2.6.60.6.10.34</td><td xmlns="" style="text-align: left;">Containment</td><td xmlns="" style="text-align: left;">ProblemOrganizer <i xmlns="http://www.w3.org/1999/xhtml"></i></td><td xmlns="" style="text-align: left;">DYNAMIC</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 2.16.840.1.113883.10.12.201 (<i xmlns="http://www.w3.org/1999/xhtml">2005‑09‑07</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">section</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">DOCSECT</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">2.16.840.1.113883.2.6.60.6.10.4</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">1.2.3.999</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">--example only--</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">22637-3</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">displayName</span><span class="ppsign">="</span><span class="ppcontent">'Pathology report 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">title</span><span class="ppsign">&gt;</span><span class="pptext">Diagnostic conclusion</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</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">author</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template CDAAuthorBody (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">author</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entry</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 2.16.840.1.113883.2.6.60.6.10.9 (dynamic) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entry</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</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:section<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>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(DiagnosticConclusionSection)</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|16px]]</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="">0 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">DOCSECT</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|16px]]</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="">0 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">EVN</td></tr><tr><td xmlns="" style="background-color: white"> </td><td xmlns="" style="vertical-align: top; text-align: left;">[[Datei:Target.png|16px]]</td><td xmlns="" colspan="4" style="background-color: #F4FFF4" class="tabtab">Ziel der Konzept Id(s): <table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="background-color: #F4FFF4"><td xmlns="" style="width: 25%; vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">psr-data&#8203;element-</span>3</td><td xmlns="" style="vertical-align: top;"></td></tr></table></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|16px]]</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>R</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(DiagnosticConclusionSection)</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</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">2.16.840.1.113883.2.6.60.6.10.4</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|16px]]</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>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=""></td><td xmlns="" style="background-color: #FFEEEE">(DiagnosticConclusionSection)</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|16px]]</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>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=""></td><td xmlns="" style="background-color: #FFEEEE">(DiagnosticConclusionSection)</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</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">22637-3</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</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">2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@displayName<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">'Pathology report diagnosis</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@codeSystemName<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">LOINC</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|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:title<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">ST</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">(DiagnosticConclusionSection)</td></tr><tr style="vertical-align: top; background-color: #FFEEEE;"><td xmlns="" style="background-color: white"> </td><td xmlns="" style="vertical-align: top;" class="conf">CONF </td><td xmlns="" colspan="4" style="background-color: white"><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="">Elementinhalt muss "Diagnostic conclusion" sein</td></tr></table></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|16px]]</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">SD.TEXT</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">(DiagnosticConclusionSection)</td></tr><tr class="explabel" style="vertical-align: top;"><td xmlns="" style="background-color: white"> </td><td xmlns="">Beispiel</td><td xmlns="" colspan="4"><div>Diagnosis</div><tt xmlns="http://www.w3.org/1999/xhtml"><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><span class="pptext"> Invasive breast cancer, no special type TNM: pT1c pN0(0/3sn) L0 V0 R0 G2 ICD-O-3: 8500/3 </span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span></tt></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|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:author<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>0 .. *</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">(DiagnosticConclusionSection)</td></tr><tr style="vertical-align: top; background-color: #FFEEEE;"><td xmlns="" style="background-color: white"> </td><td xmlns="" style="background-color: #FFEEEE">Beinhaltet</td><td xmlns="" style="background-color: #FFEEAA" colspan="3">
 .2.276.0.76.10.90025 <i xmlns="http://www.w3.org/1999/xhtml">CDA Author (Body)</i> (DYNAMIC)</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|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:entry<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 .. *</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">(DiagnosticConclusionSection)</td></tr><tr style="vertical-align: top; background-color: #FFEEEE;"><td xmlns="" style="background-color: white"> </td><td xmlns="" style="background-color: #FFEEEE">Beinhaltet</td><td xmlns="" style="background-color: #FFEEAA" colspan="3">
 .16.840.1.113883.2.6.60.6.10.34 <i xmlns="http://www.w3.org/1999/xhtml">Problem Organizer</i> (DYNAMIC)</td></tr></table></td></tr></table>

2.16.840.1.113883.2.6.60.6.10.4/static-2014-05-13T193126: Unterschied zwischen den Versionen

Version vom 28. Dezember 2015, 21:46 Uhr

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