1.2.276.0.76.10.3058/static-2015-04-24T000000: Unterschied zwischen den Versionen

Version vom 10. Juni 2016, 10:41 Uhr

Id 1.2.276.0.76.10.3058 Gültigkeit gültig ab 2015‑04‑24

Status Entwurf Versions-Label

Name GrundEinweisung Anzeigename Grund für die Einweisung

Beschreibung Grund für die Einweisung mit Hauptdiagnosen / Nebendiagnosen, Feldbezeichnungen auf dem Papierdokument: Hauptdiagnose bzw. Nebendiagnosen

Kontext Elternknoten des Template-Element mit Id 1.2.276.0.76.10.3058

Klassifikation CDA Section level template

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

Benutzt von / Benutzt

Benutzt von 1 Template, Benutzt 0 Templates

Benutzt von Template-Id	als	Name	Version
1.2.276.0.76.10.1017	Containment	Ärztlicher Kurzbericht Niedergelassener Arzt nach §90a SGB V	2015‑12‑11

Beziehung Spezialisierung: Template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Adaptation: Template 2.16.840.1.113883.10.20.22.2.43 (2015‑08‑01)
Adaptation: Template 1.3.6.1.4.1.19376.1.5.3.1.3.1 (DYNAMIC)
Adaptation: Template 1.2.276.0.76.10.3002 (DYNAMIC)

Beispiel

<section> <templateId root="1.2.276.0.76.10.3058"/> <code code="42349-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Hauptdiagnose / Nebendiagnosen</title> <text> <table border="0"> <thead> <tr> <td align="left">Hauptdiagnose (ICD-10)</td> <td align="left">J21.1</td> <td align="center">-</td> <td align="center">-</td> <td align="left">Akute Bronchiolitis durch humanes Metapneumovirus</td> </tr> </thead> <tbody> <tr> <td align="left">Nebendiagnose (ICD-10)</td> <td align="left">J31.1</td> <td align="center">V</td> <td align="center">-</td> <td align="left">V.a. Allergische Rhinopathie durch Pollen</td> </tr> <tr> <td align="left">Nebendiagnose (ICD-10)</td> <td align="left">M23.3</td> <td align="center">-</td> <td align="center">R</td> <td align="left">Sonstige Meniskusschädigungen Rechts</td> </tr> </tbody> </table> </text></section>

Item DT Kard Konf Beschreibung Label

hl7:section

(GrundEinweisung)

hl7:templateId

II

1 … 1

M

(GrundEinweisung)

@root

1 … 1

F

1.2.276.0.76.10.3058

hl7:id

II

0 … 1

(GrundEinweisung)

hl7:code

CE

1 … 1

M

(GrundEinweisung)

@code

1 … 1

F

42349-1

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)

@codeSystemName

1 … 1

F

LOINC

hl7:title

ST

1 … 1

M

(GrundEinweisung)

CONF

Elementinhalt muss "Hauptdiagnose / Nebendiagnosen" sein

hl7:text

SD.TEXT

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Textfeld ist gemäß Beispiel zu strukturieren

(GrundEinweisung)

Version vom 24. Mai 2016, 23:12 Uhr (Quelltext anzeigen) ADbot (Diskussion \| Beiträge) (Automated ADBot page content) ← Zum vorherigen Versionsunterschied		Version vom 10. Juni 2016, 10:41 Uhr (Quelltext anzeigen) ADbot (Diskussion \| Beiträge) (Automated ADBot page content) Zum nächsten Versionsunterschied →
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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 style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.276.0.76.10.3058</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;"> gültig ab 2015‑04‑24</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png\|16px]] Entwurf</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;"></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">GrundEinweisung</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Grund für die Einweisung</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beschreibung</th><td style="text-align: left;" colspan="3">Grund für die Einweisung mit Hauptdiagnosen / Nebendiagnosen, Feldbezeichnungen auf dem Papierdokument: <u>Hauptdiagnose bzw. Nebendiagnosen</u></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Kontext</th><td style="text-align: left;" colspan="3">Elternknoten des Template-Element mit Id 1.2.276.0.76.10.3058</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Section level template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Offen/Geschlossen</th><td style="text-align: left;" colspan="3">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Benutzt von / Benutzt</th><td style="text-align: left;" colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt von 1 Template, Benutzt 0 Templates</td></tr><tr><td><div><table 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 style="text-align: left;">1.2.276.0.76.10.1017</td><td style="text-align: left;">Containment</td><td style="text-align: left;"~~>AerztlicherKurzberichtNiedergelassenerArzt90a <i~~>Ärztlicher Kurzbericht Niedergelassener Arzt nach §90a SGB V~~</i>~~</td><td style="text-align: left;">2015‑12‑11</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beziehung</th><td style="text-align: left;" colspan="3">Spezialisierung: Template 2.16.840.1.113883.10.12.201 (<i>2005‑09‑07</i>)<br />Adaptation: Template 2.16.840.1.113883.10.20.22.2.43 (<i>2015‑08‑01</i>)<br />Adaptation: Template 1.3.6.1.4.1.19376.1.5.3.1.3.1 (<i>DYNAMIC</i>)<br />Adaptation: Template 1.2.276.0.76.10.3002 (<i>DYNAMIC</i>)</td></tr><tr class="explabel" style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;"><span class="expcaption">Beispiel</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">section</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.3058</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">42349-1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">title</span><span class="ppsign">></span><span class="pptext">Hauptdiagnose / Nebendiagnosen</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">text</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">table</span> <span class="ppattribute">border</span><span class="ppsign">="</span><span class="ppcontent">0</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">thead</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">tr</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">Hauptdiagnose (ICD-10)</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">J21.1</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">-</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">-</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">Akute Bronchiolitis durch humanes Metapneumovirus</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">thead</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">tbody</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">tr</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">Nebendiagnose (ICD-10)</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">J31.1</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">V</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">-</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">V.a. Allergische Rhinopathie durch Pollen</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">tr</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">Nebendiagnose (ICD-10)</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">M23.3</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">-</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">R</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">Sonstige Meniskusschädigungen Rechts</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">tbody</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">table</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">></span></span></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Kard</th><th style="width: 2em; text-align: left;">Konf</th><th style="text-align: left;">Beschreibung</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:section<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;">(GrundEinweisung)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;">(GrundEinweisung)</td></tr><tr><td style="vertical-align: top;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png\|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td></td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;">(GrundEinweisung)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>hl7:code<br /></strong></tt></td></tr></table></td><td><strong>CE</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;">(GrundEinweisung)</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png\|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>@code<br /></strong></tt></td></tr></table></td><td></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td>F</td><td colspan="2">42349-1</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png\|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td>F</td><td colspan="2">2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png\|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>@codeSystemName<br /></strong></tt></td></tr></table></td><td></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td>F</td><td colspan="2">LOINC</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>hl7:title<br /></strong></tt></td></tr></table></td><td><strong>ST</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;">(GrundEinweisung)</td></tr><tr style="vertical-align: top; background-color: #FFEEEE;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4" style="background-color: white;"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Elementinhalt muss "Hauptdiagnose / Nebendiagnosen" sein</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>hl7:text<br /></strong></tt></td></tr></table></td><td><strong>SD.TEXT</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td>Textfeld ist gemäß Beispiel zu strukturieren</td><td style="background-color: #FFEEEE;">(GrundEinweisung)</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 style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.276.0.76.10.3058</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;"> gültig ab 2015‑04‑24</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png\|16px]] Entwurf</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;"></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">GrundEinweisung</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Grund für die Einweisung</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beschreibung</th><td style="text-align: left;" colspan="3">Grund für die Einweisung mit Hauptdiagnosen / Nebendiagnosen, Feldbezeichnungen auf dem Papierdokument: <u>Hauptdiagnose bzw. Nebendiagnosen</u></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Kontext</th><td style="text-align: left;" colspan="3">Elternknoten des Template-Element mit Id 1.2.276.0.76.10.3058</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Section level template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Offen/Geschlossen</th><td style="text-align: left;" colspan="3">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Benutzt von / Benutzt</th><td style="text-align: left;" colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt von 1 Template, Benutzt 0 Templates</td></tr><tr><td><div><table 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 style="text-align: left;">1.2.276.0.76.10.1017</td><td style="text-align: left;">Containment</td><td style="text-align: left;">Ärztlicher Kurzbericht Niedergelassener Arzt nach §90a SGB V</td><td style="text-align: left;">2015‑12‑11</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beziehung</th><td style="text-align: left;" colspan="3">Spezialisierung: Template 2.16.840.1.113883.10.12.201 (<i>2005‑09‑07</i>)<br />Adaptation: Template 2.16.840.1.113883.10.20.22.2.43 (<i>2015‑08‑01</i>)<br />Adaptation: Template 1.3.6.1.4.1.19376.1.5.3.1.3.1 (<i>DYNAMIC</i>)<br />Adaptation: Template 1.2.276.0.76.10.3002 (<i>DYNAMIC</i>)</td></tr><tr class="explabel" style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;"><span class="expcaption">Beispiel</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">section</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.3058</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">42349-1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">title</span><span class="ppsign">></span><span class="pptext">Hauptdiagnose / Nebendiagnosen</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">text</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">table</span> <span class="ppattribute">border</span><span class="ppsign">="</span><span class="ppcontent">0</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">thead</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">tr</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">Hauptdiagnose (ICD-10)</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">J21.1</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">-</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">-</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">Akute Bronchiolitis durch humanes Metapneumovirus</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">thead</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">tbody</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">tr</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">Nebendiagnose (ICD-10)</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">J31.1</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">V</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">-</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">V.a. Allergische Rhinopathie durch Pollen</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">tr</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">Nebendiagnose (ICD-10)</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">M23.3</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">-</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">R</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">Sonstige Meniskusschädigungen Rechts</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">tbody</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">table</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">></span></span></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Kard</th><th style="width: 2em; text-align: left;">Konf</th><th style="text-align: left;">Beschreibung</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:section<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;">(GrundEinweisung)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;">(GrundEinweisung)</td></tr><tr><td style="vertical-align: top;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png\|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td></td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.276.0.76.10.3058</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;">(GrundEinweisung)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>hl7:code<br /></strong></tt></td></tr></table></td><td><strong>CE</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;">(GrundEinweisung)</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png\|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>@code<br /></strong></tt></td></tr></table></td><td></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td>F</td><td colspan="2">42349-1</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png\|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td>F</td><td colspan="2">2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png\|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>@codeSystemName<br /></strong></tt></td></tr></table></td><td></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td>F</td><td colspan="2">LOINC</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>hl7:title<br /></strong></tt></td></tr></table></td><td><strong>ST</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;">(GrundEinweisung)</td></tr><tr style="vertical-align: top; background-color: #FFEEEE;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4" style="background-color: white;"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Elementinhalt muss "Hauptdiagnose / Nebendiagnosen" sein</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>hl7:text<br /></strong></tt></td></tr></table></td><td><strong>SD.TEXT</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td>Textfeld ist gemäß Beispiel zu strukturieren</td><td style="background-color: #FFEEEE;">(GrundEinweisung)</td></tr></table></td></tr></table>

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