1.2.276.0.76.3.1.261.1.10.3.6/static-2018-06-04T000000: Unterschied zwischen den Versionen
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| − | <table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.276.0.76.3.1.261.1.10.3.6</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2018‑06‑04<div>Andere Versionen mit dieser Id:<ul></ul></div></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] 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;">Dischargediagnosissection2</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Entlassungsdiagnose</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beschreibung</th><td style="text-align: left;" colspan="3">Diagnose, mit der der Patient entlassen wurde<br /></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;">Assoziiert mit</th><td style="text-align: left;" colspan="3"><table class="treetable" id="assocsTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Assoziiert mit 1 Konzept</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;">Id</th><th style="width: 60%; text-align: left;">Name</th><th style="width: 20%; text-align: left;">Datensatz</th></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;"><span style="color: grey;">dguvbbr-data​element2-</span>100</td><td style="vertical-align: top;">[[File:Kyellow.png|14px]] Diagnosen/Probleme </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Stationärer Entlassungsbericht </td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">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 2 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</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;">1.2.276.0.76.3.1.261.1.10.4.14</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Diagnose Observation</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.276.0.76.3.1.261.1.10.4.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Klassifikation Observation</td><td style="text-align: left;">DYNAMIC</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> </i> (2005‑09‑07)</td></tr><tr class="explabel " style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelblue"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Beispiel zur Textformatierung der Diagnosen in Form von Tabellen</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">1.2.276.0.76.3.1.261.1.10.3.2</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></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">29548-5</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></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">title</span><span class="ppsign">></span><span class="pptext">Entlassungsdiagnosen</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">1</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">th</span><span class="ppsign">></span><span class="pptext">Diagnose</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">th</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">th</span><span class="ppsign">></span><span class="pptext">ICD Code</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">th</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">th</span><span class="ppsign">></span><span class="pptext">Lokalisation</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">th</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">th</span><span class="ppsign">></span><span class="pptext">Zusatz</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">th</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="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">content</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">diag_1</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">Beckenringfraktur</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">content</span><span class="ppsign">></span></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="ppsign">></span><span class="pptext">S32.8</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="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="ppsign">></span><span class="pptext">G</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 class="columnName"><table class="ad-diffblock-horizontal " 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;"><span title="">(Dis...on2)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-data​element2-</span>100</td><td style="vertical-align: top;">[[File:Kyellow.png|14px]] Diagnosen/Probleme </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Stationärer Entlassungsbericht </td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " 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></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Dis...on2)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><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>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.276.0.76.3.1.261.1.10.3.6</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " 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;"><span title="">(Dis...on2)</span></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 rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">11535-2</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><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " 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;"><span title="">(Dis...on2)</span></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 "Entlassungsdiagnosen" sein</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " 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></td><td style="background-color: #FFEEEE;"><span title="">(Dis...on2)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entry<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.276.0.76.3.1.261.1.10.4.14 <i>Diagnose Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Dis...on2)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo <i> [hl7:observation [hl7:code [(@code = '52534-5' and @codeSystem = '2.16.840.1.113883.6.1') or (@code = '81885-6' and @codeSystem = '2.16.840.1.113883.6.1')]]]</i></td></tr></table></td><td></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2">[[File:Kred.png|14px]] error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">.//hl7:observation[hl7:templateId/@root='1.2.276.0.76.3.1.261.1.10.4.14']/hl7:code[@code=('52534-5','81885-6')]</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">Der Code für die Diagnose-Observation muss 52534-5 LOIINC für die Hauptdiagnose oder 81885-6 LOINC für die Nebendiagnosen sein</span></td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entry<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.276.0.76.3.1.261.1.10.4.7 <i>Klassifikation Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Dis...on2)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo <i> [hl7:observation [hl7:code [concat(@code, @codeSystem) = doc('include/voc-1.2.276.0.76.3.1.261.1.11.8-DYNAMIC.xml')//valueSet [1]/conceptList/concept/concat(@code, @codeSystem)]]]</i></td></tr></table></td><td></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4">AO-Klassifikation ausfüllen, wenn die Hauptdiagnose laut ICD-10 eine Fraktur ist<br /><br /><table class="artdecor" style="background: transparent;"><tr><th>Region/Klasse</th><th>Code inkl. aller Unterklassen</th></tr><tr><td>S02.- Fraktur des Schädels und der Gesichtsschädelknochen</td><td>S02.0 - S02.09</td></tr><tr><td>S12.- Fraktur im Bereich des Halses</td><td>S12.0 - S12.9</td></tr><tr><td>S22.- Fraktur der Rippe(n), des Sternums und der Brustwirbelsäule</td><td>S22.0 - S22.9</td></tr><tr><td>S32.- Fraktur der Lendenwirbelsäule und des Beckens</td><td>S32.0 - S32.89</td></tr><tr><td>S42.- Fraktur im Bereich der Schulter und des Oberarmes</td><td>S42.0 - S42.9</td></tr><tr><td>S52.- Fraktur des Unterarmes</td><td>S52.0 - S52.9</td></tr><tr><td>S62.- Fraktur im Bereich des Handgelenkes und der Hand</td><td>S62.0 - S62.8</td></tr><tr><td>S72.- Fraktur des Femurs</td><td>S72.0 - S72.9</td></tr><tr><td>S82.- Fraktur des Unterschenkels, einschließlich des oberen Sprunggelenkes</td><td>S82.0 - S82.9</td></tr><tr><td>S92.- Fraktur des Fußes [ausgenommen oberes Sprunggelenk]</td><td>S92.0 - S92.9</td></tr><tr><td>T02.- Frakturen mit Beteiligung mehrerer Körperregionen</td><td>T02.0 - T02.91</td></tr><tr><td>T08.- Fraktur der Wirbelsäule, Höhe nicht näher bezeichnet</td><td>T08.0 | + | <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;">1.2.276.0.76.3.1.261.1.10.3.6</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2018‑06‑04<div>Andere Versionen mit dieser Id:<ul></ul></div></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] 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;">Dischargediagnosissection2</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Entlassungsdiagnose</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beschreibung</th><td style="text-align: left;" colspan="3">Diagnose, mit der der Patient entlassen wurde<br /></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;">Assoziiert mit</th><td style="text-align: left;" colspan="3"><table class="treetable" id="assocsTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Assoziiert mit 1 Konzept</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;">Id</th><th style="width: 60%; text-align: left;">Name</th><th style="width: 20%; text-align: left;">Datensatz</th></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;"><span style="color: grey;">dguvbbr-data​element2-</span>100</td><td style="vertical-align: top;">[[File:Kyellow.png|14px]] Diagnosen/Probleme </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Stationärer Entlassungsbericht </td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">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 2 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</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;">1.2.276.0.76.3.1.261.1.10.4.14</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Diagnose Observation</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.276.0.76.3.1.261.1.10.4.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Klassifikation Observation</td><td style="text-align: left;">DYNAMIC</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> </i> (2005‑09‑07)</td></tr><tr class="explabel " style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelblue"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Beispiel zur Textformatierung der Diagnosen in Form von Tabellen</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">1.2.276.0.76.3.1.261.1.10.3.2</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></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">29548-5</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></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">title</span><span class="ppsign">></span><span class="pptext">Entlassungsdiagnosen</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">1</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">th</span><span class="ppsign">></span><span class="pptext">Diagnose</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">th</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">th</span><span class="ppsign">></span><span class="pptext">ICD Code</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">th</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">th</span><span class="ppsign">></span><span class="pptext">Lokalisation</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">th</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">th</span><span class="ppsign">></span><span class="pptext">Zusatz</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">th</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="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">content</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">diag_1</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">Beckenringfraktur</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">content</span><span class="ppsign">></span></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="ppsign">></span><span class="pptext">S32.8</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="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="ppsign">></span><span class="pptext">G</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 class="columnName"><table class="ad-diffblock-horizontal " 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;"><span title="">(Dis...on2)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-data​element2-</span>100</td><td style="vertical-align: top;">[[File:Kyellow.png|14px]] Diagnosen/Probleme </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Stationärer Entlassungsbericht </td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " 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></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Dis...on2)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><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>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.276.0.76.3.1.261.1.10.3.6</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " 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;"><span title="">(Dis...on2)</span></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 rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">11535-2</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><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " 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;"><span title="">(Dis...on2)</span></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 "Entlassungsdiagnosen" sein</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " 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></td><td style="background-color: #FFEEEE;"><span title="">(Dis...on2)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entry<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.276.0.76.3.1.261.1.10.4.14 <i>Diagnose Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Dis...on2)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo <i> [hl7:observation [hl7:code [(@code = '52534-5' and @codeSystem = '2.16.840.1.113883.6.1') or (@code = '81885-6' and @codeSystem = '2.16.840.1.113883.6.1')]]]</i></td></tr></table></td><td></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2">[[File:Kred.png|14px]] error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">.//hl7:observation[hl7:templateId/@root='1.2.276.0.76.3.1.261.1.10.4.14']/hl7:code[@code=('52534-5','81885-6')]</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">Der Code für die Diagnose-Observation muss 52534-5 LOIINC für die Hauptdiagnose oder 81885-6 LOINC für die Nebendiagnosen sein</span></td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entry<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.276.0.76.3.1.261.1.10.4.7 <i>Klassifikation Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Dis...on2)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo <i> [hl7:observation [hl7:code [concat(@code, @codeSystem) = doc('include/voc-1.2.276.0.76.3.1.261.1.11.8-DYNAMIC.xml')//valueSet [1]/conceptList/concept/concat(@code, @codeSystem)]]]</i></td></tr></table></td><td></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4">AO-Klassifikation ausfüllen, wenn die Hauptdiagnose laut ICD-10 eine Fraktur ist<br /> |
| + | <br /> | ||
| + | <table class="artdecor" style="background: transparent;"><tr><th colspan="1" rowspan="1">Region/Klasse</th><th colspan="1" rowspan="1">Code inkl. aller Unterklassen</th></tr><tr><td colspan="1" rowspan="1">S02.- Fraktur des Schädels und der Gesichtsschädelknochen</td><td colspan="1" rowspan="1">S02.0 - S02.09</td></tr><tr><td colspan="1" rowspan="1">S12.- Fraktur im Bereich des Halses</td><td colspan="1" rowspan="1">S12.0 - S12.9</td></tr><tr><td colspan="1" rowspan="1">S22.- Fraktur der Rippe(n), des Sternums und der Brustwirbelsäule</td><td colspan="1" rowspan="1">S22.0 - S22.9</td></tr><tr><td colspan="1" rowspan="1">S32.- Fraktur der Lendenwirbelsäule und des Beckens</td><td colspan="1" rowspan="1">S32.0 - S32.89</td></tr><tr><td colspan="1" rowspan="1">S42.- Fraktur im Bereich der Schulter und des Oberarmes</td><td colspan="1" rowspan="1">S42.0 - S42.9</td></tr><tr><td colspan="1" rowspan="1">S52.- Fraktur des Unterarmes</td><td colspan="1" rowspan="1">S52.0 - S52.9</td></tr><tr><td colspan="1" rowspan="1">S62.- Fraktur im Bereich des Handgelenkes und der Hand</td><td colspan="1" rowspan="1">S62.0 - S62.8</td></tr><tr><td colspan="1" rowspan="1">S72.- Fraktur des Femurs</td><td colspan="1" rowspan="1">S72.0 - S72.9</td></tr><tr><td colspan="1" rowspan="1">S82.- Fraktur des Unterschenkels, einschließlich des oberen Sprunggelenkes</td><td colspan="1" rowspan="1">S82.0 - S82.9</td></tr><tr><td colspan="1" rowspan="1">S92.- Fraktur des Fußes [ausgenommen oberes Sprunggelenk]</td><td colspan="1" rowspan="1">S92.0 - S92.9</td></tr><tr><td colspan="1" rowspan="1">T02.- Frakturen mit Beteiligung mehrerer Körperregionen</td><td colspan="1" rowspan="1">T02.0 - T02.91</td></tr><tr><td colspan="1" rowspan="1">T08.- Fraktur der Wirbelsäule, Höhe nicht näher bezeichnet</td><td colspan="1" rowspan="1">T08.0 - T08.1</td></tr><tr><td colspan="1" rowspan="1">T10.- Fraktur der oberen Extremität, Höhe nicht näher bezeichnet</td><td colspan="1" rowspan="1">T10.0 - T10.1</td></tr><tr><td colspan="1" rowspan="1">T12.- Fraktur der unteren Extremität, Höhe nicht näher bezeichnet</td><td colspan="1" rowspan="1">T12.0 - T12.1</td></tr><tr><td colspan="1" rowspan="1">T14.- Verletzung an einer nicht näher bezeichneten Körperregion</td><td colspan="1" rowspan="1">T14.2 - T14.21</td></tr><tr><td colspan="1" rowspan="1">M80.- Osteoporose mit pathologischer Fraktur</td><td colspan="1" rowspan="1">M80.0 - M80.99</td></tr></table></td></tr></table></td></tr></table> | ||
Version vom 17. August 2018, 02:52 Uhr
| Id | 1.2.276.0.76.3.1.261.1.10.3.6 | Gültigkeit | 2018‑06‑04 Andere Versionen mit dieser Id: | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Status |  Entwurf | Versions-Label | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Name | Dischargediagnosissection2 | Anzeigename | Entlassungsdiagnose | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Beschreibung | Diagnose, mit der der Patient entlassen wurde | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Klassifikation | CDA Section level template | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Offen/Geschlossen | Offen (auch andere als die definierten Elemente sind erlaubt) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Assoziiert mit |
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| Benutzt |
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| Beziehung | Spezialisierung: Template 2.16.840.1.113883.10.12.201 (2005‑09‑07) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Beispiel |
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