1.2.276.0.76.10.1021/static-2016-11-01T000000/hlist: Unterschied zwischen den Versionen

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<li class="ad-template"><div class="nowrapinline ad-templatetype cdadocumentlevel"> Document </div> Trauma Summary CDA document ([[1.2.276.0.76.10.1021]])
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                            <div class="nowrapinline ad-templatetype cdadocumentlevel"> Document</div>&#160;Trauma Summary CDA document ([[1.2.276.0.76.10.1021]])<ol>
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Version vom 6. Juli 2017, 14:32 Uhr

  1. Document
     Trauma Summary CDA document (1.2.276.0.76.10.1021)
    1. Header
       CDA realmCode (1.2.276.0.76.10.90002)
    2. Header
       CDA typeId (1.2.276.0.76.10.90003)
    3. Header
       CDA id (1.2.276.0.76.10.90004)
    4. Header
       CDA title (1.2.276.0.76.10.90005)
    5. Header
       CDA effectiveTime (1.2.276.0.76.10.90006)
    6. Header
       CDA confidentialityCode (1.2.276.0.76.10.90007)
    7. Header
       CDA languageCode (1.2.276.0.76.10.90008)
    8. Header
       CDA setId and versionNumber (1.2.276.0.76.10.90009)
    9. Header
       CDA recordTarget (nnar) (1.2.276.0.76.10.2032)
      1. Header
         Patientenidentifikation (1.2.276.0.76.10.90024)
    10. Header
       CDA author (1.2.276.0.76.10.2033)
      1. Header
         CDA Person Elements (1.2.276.0.76.10.90010)
      2. Header
         CDA Organization Elements (1.2.276.0.76.10.90011)
    11. Header
       CDA custodian (1.2.276.0.76.10.2034)
      1. Header
         CDA Organization Elements (1.2.276.0.76.10.90011)
    12. Header
       CDA informationRecipient (1.2.276.0.76.10.2005)
      1. Header
         CDA Person Elements (1.2.276.0.76.10.90010)
      2. Header
         CDA Organization Elements (1.2.276.0.76.10.90011)
    13. Header
       Dienstleistung/Behandlung (Trauma) (1.2.276.0.76.10.2042)
    14. Section
       Unfallereignis (1.2.276.0.76.10.3068)
      1. Entry
         Injury Event Detail (1.2.276.0.76.10.4088)
        1. Entry
           Trauma Injury Observation Organizer (1.2.276.0.76.10.4089)
          1. Entry
             Traumatic Injury Observation (1.2.276.0.76.10.4092)
          2. Entry
             Injury Severity Score Body Region Observation (1.2.276.0.76.10.4168)
          3. Entry
             Injury Severity Observation (1.2.276.0.76.10.4167)
        2. Entry
           Injury Cause Observation Organizer (1.2.276.0.76.10.4090)
          1. Entry
             Primary Injury Cause Observation (1.2.276.0.76.10.4095)
        3. Entry
           Safety Equipment Observation Organizer (1.2.276.0.76.10.4091)
          1. Entry
             Safety Equipment Used Observation (1.2.276.0.76.10.4096)
        4. Entry
           Pre-trauma ASA score (1.2.276.0.76.10.4169)
    15. Section
       Präklinik (Episode) (1.2.276.0.76.10.3069)
      1. Entry
         PreHospital Encounter Entry (1.2.276.0.76.10.4097)
        1. Entry
           Prehospital Encounter Response Observation Organizer (1.2.276.0.76.10.4099)
          1. Entry
             Prehospital Encounter Response Unit Scene Arrival Observation (1.2.276.0.76.10.4163)
          2. Entry
             Prehospital Encounter Response Unit Scene Departure Observation (1.2.276.0.76.10.4164)
        2. Entry
           Transportation Observation Organizer (1.2.276.0.76.10.4100)
          1. Entry
             Alarmierungszeit Rettungsmittel (1.2.276.0.76.10.4098)
        3. Entry
           Vital Sign Observations Organizer (1.2.276.0.76.10.4101)
          1. Entry
             Atemfrequenz (1.2.276.0.76.10.4030)
          2. Entry
             Herzfrequenz (1.2.276.0.76.10.4033)
          3. Entry
             Glasgow Coma Scale (1.2.276.0.76.10.4034)
          4. Entry
             Pupillenweite (1.2.276.0.76.10.4046)
          5. Entry
             Pupillenreaktion (1.2.276.0.76.10.4047)
          6. Entry
             Körperkerntemperatur (1.2.276.0.76.10.4035)
          7. Entry
             Schmerz (1.2.276.0.76.10.4036)
          8. Entry
             Endtidales CO2 (1.2.276.0.76.10.4103)
        4. Entry
           Intoxications Observations Organizer (1.2.276.0.76.10.4102)
          1. Entry
             Intoxication Alcohol Drug Observation (1.2.276.0.76.10.4104)
        5. Entry
           FAST Befunde (1.2.276.0.76.10.4105)
          1. Entry
             FAST Befunde freie Flüssigkeit (1.2.276.0.76.10.4134)
        6. Entry
           Prehospital procedures performed Organizer (1.2.276.0.76.10.4106)
          1. Entry
             HWS Immobilisation (1.2.276.0.76.10.4107)
          2. Entry
             Endotracheale Intubation (1.2.276.0.76.10.4108)
          3. Entry
             Supraglottische Atemwegshilfe (1.2.276.0.76.10.4109)
          4. Entry
             Chirurgische Atemwegssicherung (1.2.276.0.76.10.4110)
          5. Entry
             Thoraxdrainage (1.2.276.0.76.10.4111)
          6. Entry
             Periphervenöser Zugang (1.2.276.0.76.10.4113)
          7. Entry
             Zentralvenöser Zugang (1.2.276.0.76.10.4114)
          8. Entry
             Arterieller Zugang (1.2.276.0.76.10.4115)
          9. Entry
             Intraossärer Zugang (1.2.276.0.76.10.4116)
          10. Entry
             Herzdruckmassage (1.2.276.0.76.10.4117)
          11. Entry
             Defibrillation (1.2.276.0.76.10.4118)
          12. Entry
             Blutstillung (1.2.276.0.76.10.4119)
          13. Entry
             Frakturbehandlung (1.2.276.0.76.10.4120)
          14. Entry
             Beckengurt (1.2.276.0.76.10.4121)
          15. Entry
             Analgosedierung (1.2.276.0.76.10.4122)
          16. Entry
             Thermoprotektion (1.2.276.0.76.10.4123)
          17. Entry
             Reanimation (1.2.276.0.76.10.4124)
          18. Entry
             Kristalloide Infusionslösungen (1.2.276.0.76.10.4125)
          19. Entry
             Kolloidale Infusionslösungen (1.2.276.0.76.10.4126)
          20. Entry
             Small-volume Gabe (1.2.276.0.76.10.4252)
          21. Entry
             Katecholamine (1.2.276.0.76.10.4127)
          22. Entry
             Tranexamsäure (1.2.276.0.76.10.4128)
    16. Section
       Körperliche Untersuchung (1.2.276.0.76.10.3072)
    17. Section
       Klinik (Episode) (1.2.276.0.76.10.3073)
      1. Entry
         Hospital Care Episode Encounter (1.2.276.0.76.10.4133)
        1. Entry
           Inpatient Hospital Encounter Detail Observation Organizer (1.2.276.0.76.10.4136)
          1. Entry
             Relevant Blood Loss (1.2.276.0.76.10.4137)
          2. Entry
             Endtidales CO2 (1.2.276.0.76.10.4103)
          3. Entry
             FAST Befunde (1.2.276.0.76.10.4105)
            1. Entry
               FAST Befunde freie Flüssigkeit (1.2.276.0.76.10.4134)
          4. Entry
             Bildgebende Befunde (1.2.276.0.76.10.4135)
      2. Section
         Schockraum Episode (1.2.276.0.76.10.3071)
        1. Entry
           Emergency Room Encounter Entry (1.2.276.0.76.10.4129)
          1. Entry
             Emergency Room procedures performed Organizer (1.2.276.0.76.10.4130)
            1. Entry
               HWS Immobilisation (1.2.276.0.76.10.4107)
            2. Entry
               Endotracheale Intubation (1.2.276.0.76.10.4108)
            3. Entry
               Supraglottische Atemwegshilfe (1.2.276.0.76.10.4109)
            4. Entry
               Chirurgische Atemwegssicherung (1.2.276.0.76.10.4110)
            5. Entry
               Thoraxdrainage (1.2.276.0.76.10.4111)
            6. Entry
               Periphervenöser Zugang (1.2.276.0.76.10.4113)
            7. Entry
               Zentralvenöser Zugang (1.2.276.0.76.10.4114)
            8. Entry
               Arterieller Zugang (1.2.276.0.76.10.4115)
            9. Entry
               Intraossärer Zugang (1.2.276.0.76.10.4116)
            10. Entry
               Herzdruckmassage (1.2.276.0.76.10.4117)
            11. Entry
               Defibrillation (1.2.276.0.76.10.4118)
            12. Entry
               Blutstillung (1.2.276.0.76.10.4119)
            13. Entry
               Frakturbehandlung (1.2.276.0.76.10.4120)
            14. Entry
               Beckengurt (1.2.276.0.76.10.4121)
            15. Entry
               Analgosedierung (1.2.276.0.76.10.4122)
            16. Entry
               Thermoprotektion (1.2.276.0.76.10.4123)
            17. Entry
               Reanimation (1.2.276.0.76.10.4124)
            18. Entry
               Kristalloide Infusionslösungen (1.2.276.0.76.10.4125)
            19. Entry
               Kolloidale Infusionslösungen (1.2.276.0.76.10.4126)
            20. Entry
               Small-volume Gabe (1.2.276.0.76.10.4252)
            21. Entry
               Katecholamine (1.2.276.0.76.10.4127)
      3. Section
         Aufnahmelabor (1.2.276.0.76.10.3074)
        1. Entry
           Laboratory Results Organizer (1.2.276.0.76.10.4138)
          1. Entry
             pH (1.2.276.0.76.10.4139)
          2. Entry
             Base Excess (1.2.276.0.76.10.4140)
          3. Entry
             Hb (1.2.276.0.76.10.4141)
          4. Entry
             Thrombozytenzahl (1.2.276.0.76.10.4142)
          5. Entry
             Quick (1.2.276.0.76.10.4144)
          6. Entry
             aPTT (1.2.276.0.76.10.4145)
          7. Entry
             INR (1.2.276.0.76.10.4146)
          8. Entry
             Fibrinogen (1.2.276.0.76.10.4147)
          9. Entry
             Ionisiertes Kalzium (1.2.276.0.76.10.4148)
          10. Entry
             Ethanol (Plasma) (1.2.276.0.76.10.4149)
          11. Entry
             ROTEM (1.2.276.0.76.10.4150)
            1. Entry
               ROTEM EXTEM-CT (1.2.276.0.76.10.4151)
            2. Entry
               ROTEM EXTEM-MCF (1.2.276.0.76.10.4152)
            3. Entry
               ROTEM A10 FIBTEM (1.2.276.0.76.10.4153)
      4. Section
         Antikoagulation (1.2.276.0.76.10.3075)
        1. Entry
           Antikoagulans (1.2.276.0.76.10.4154)
      5. Section
         Notfalleingriffe (1.2.276.0.76.10.3076)
        1. Entry
           Hirndruckentlastung (1.2.276.0.76.10.4155)
        2. Entry
           Laminektomie (1.2.276.0.76.10.4156)
        3. Entry
           Thorakotomie (1.2.276.0.76.10.4157)
        4. Entry
           Laparotomie (1.2.276.0.76.10.4158)
        5. Entry
           Revaskularisation (1.2.276.0.76.10.4159)
        6. Entry
           Embolisation (1.2.276.0.76.10.4160)
        7. Entry
           Beckenstabilisierung (1.2.276.0.76.10.4161)
        8. Entry
           Stabilisierung Extremitäten (1.2.276.0.76.10.4162)
      6. Section
         Imaging Results (1.2.276.0.76.10.3078)
    18. Section
       Abschlussdiagnosen (Trauma) (1.2.276.0.76.10.3077)
      1. Entry
         Problem Concern Act (Abschlussdiagnosen) (1.2.276.0.76.10.4048)
        1. Entry
           Problem Observation (Abschlussdiagnose) (1.2.276.0.76.10.4049)
          1. Entry
             Diagnosesicherheit (1.2.276.0.76.10.90027)
          2. Entry
             Lateralität (1.2.276.0.76.10.90026)
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