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Aktuelle Version vom 5. Januar 2021, 16:01 Uhr

  1. Document
     Patientenbezogener pflegerischer Verlegungs- oder Entlassungsbericht 2017/2018 (2.16.840.1.113883.3.1937.99.61.34.10.1)
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    22. Section
       Anrede (1.2.276.0.76.10.3001)
    23. Section
       Pflegeprozess Section (1.2.276.0.76.10.3003)
      1. Section
         Pflegediagnose Section (1.2.276.0.76.10.3004)
        1. Entry
           Pflegediagnose - Entry (2.16.840.1.113883.3.1937.99.61.34.10.27)
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        2. Section
           Hilfsmittel (2.16.840.1.113883.3.1937.99.61.34.10.20)
          1. Entry
             Hilfsmittel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.38)
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               CDA effectiveTime (1.2.276.0.76.10.90006)
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               Manufactured Product (2.16.840.1.113883.3.1937.99.61.34.10.40)
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               Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
        3. Section
           Ätiologie Section (1.2.276.0.76.10.3007)
        4. Section
           Symptome Section (1.2.276.0.76.10.3008)
        5. Section
           Ressource Section (1.2.276.0.76.10.3009)
        6. Section
           Pflegeintervention Section (1.2.276.0.76.10.3010)
          1. Entry
             Pflegeintervention - Entry (2.16.840.1.113883.3.1937.99.61.34.10.30)
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          2. Section
             Pflegeergebnis Section (1.2.276.0.76.10.3011)
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               Pflegeergebnis - Entry (2.16.840.1.113883.3.1937.99.61.34.10.31)
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                 CDA effectiveTime (1.2.276.0.76.10.90006)
      2. Section
         Assessment Section_Pflegebericht (2.16.840.1.113883.3.1937.99.61.34.10.42)
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           Score - Entry (2.16.840.1.113883.3.1937.99.61.34.10.29)
          1. Header
             CDA effectiveTime (1.2.276.0.76.10.90006)
        2. Section
           Hilfsmittel (2.16.840.1.113883.3.1937.99.61.34.10.20)
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             Hilfsmittel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.38)
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               Manufactured Product (2.16.840.1.113883.3.1937.99.61.34.10.40)
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                 Manufactured Material (2.16.840.1.113883.3.1937.99.61.34.10.39)
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               Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
        3. Section
           Pflegeziel Section (1.2.276.0.76.10.3006)
          1. Entry
             Pflegeziel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.32)
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          2. Section
             Hilfsmittel (2.16.840.1.113883.3.1937.99.61.34.10.20)
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               Hilfsmittel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.38)
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                   Manufactured Material (2.16.840.1.113883.3.1937.99.61.34.10.39)
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                 Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
          3. Section
             Ressource Section (1.2.276.0.76.10.3009)
          4. Section
             Pflegeintervention Section (1.2.276.0.76.10.3010)
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               Pflegeintervention - Entry (2.16.840.1.113883.3.1937.99.61.34.10.30)
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                 Pflegeergebnis - Entry (2.16.840.1.113883.3.1937.99.61.34.10.31)
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        4. Section
           Pflegeintervention Section (1.2.276.0.76.10.3010)
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             Pflegeintervention - Entry (2.16.840.1.113883.3.1937.99.61.34.10.30)
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               Pflegeergebnis - Entry (2.16.840.1.113883.3.1937.99.61.34.10.31)
              1. Header
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      3. Section
         Pflegeziel Section (1.2.276.0.76.10.3006)
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           Pflegeziel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.32)
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           Hilfsmittel (2.16.840.1.113883.3.1937.99.61.34.10.20)
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             Hilfsmittel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.38)
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        3. Section
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        4. Section
           Pflegeintervention Section (1.2.276.0.76.10.3010)
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    24. Section
       SocialInformation (2.16.840.1.113883.3.1937.99.61.34.10.8)
      1. Section
         Ausgeübter Beruf (2.16.840.1.113883.3.1937.99.61.34.10.2)
    25. Section
       HomeCareStatus (2.16.840.1.113883.3.1937.99.61.34.10.21)
      1. Section
         Barrierefreiheit (2.16.840.1.113883.3.1937.99.61.34.10.17)
        1. Section
           Zugang zur Wohnung (2.16.840.1.113883.3.1937.99.61.34.10.16)
        2. Section
           Barrierefreiheit in der Wohnung (2.16.840.1.113883.3.1937.99.61.34.10.15)
        3. Section
           Wohnraumanpassung (2.16.840.1.113883.3.1937.99.61.34.10.14)
          1. notype
             Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
        4. Section
           Wohnumfeldberatung (2.16.840.1.113883.3.1937.99.61.34.10.13)
      2. Section
         Wohnform (2.16.840.1.113883.3.1937.99.61.34.10.19)
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      3. Section
         Hilfsmittel (2.16.840.1.113883.3.1937.99.61.34.10.20)
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           Hilfsmittel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.38)
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             Manufactured Product (2.16.840.1.113883.3.1937.99.61.34.10.40)
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          3. notype
             Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
    26. Section
       Sozialrechtliche Informationen (2.16.840.1.113883.3.1937.99.61.34.10.26)
      1. Section
         Bestellung eines Betreuers (2.16.840.1.113883.3.1937.99.61.34.10.25)
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           Betreuer (2.16.840.1.113883.3.1937.99.61.34.10.34)
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        2. Entry
           Vormundschaftsgericht (2.16.840.1.113883.3.1937.99.61.34.10.33)
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      2. Section
         Hilfe nach SGB XII (2.16.840.1.113883.3.1937.99.61.34.10.24)
        1. Entry
           Hilfe zur Pflege nach SGB XII (L3) (2.16.840.1.113883.3.1937.99.61.34.10.35)
        2. notype
           Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
        3. *
           spezielle Kontaktperson (2.16.840.1.113883.3.1937.99.61.34.10.43)
      3. Section
         Pflegegrad (2.16.840.1.113883.3.1937.99.61.34.10.9)
        1. Entry
           Pflegegrad (2.16.840.1.113883.3.1937.99.61.34.10.7)
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             Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
        2. notype
           Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
        3. *
           spezielle Kontaktperson (2.16.840.1.113883.3.1937.99.61.34.10.43)
      4. Section
         Verfügungen (2.16.840.1.113883.3.1937.99.61.34.10.22)
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        2. Header
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    27. Section
       Medizinische Informationen (2.16.840.1.113883.3.1937.99.61.34.10.4)
      1. Section
         Aufnahmediagnose (1.2.276.0.76.10.3026)
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           Diagnose Concern Act (1.2.276.0.76.10.4079)
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             Author (Body) (1.2.276.0.76.10.90025)
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               CDA Person Elements (1.2.276.0.76.10.90010)
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               CDA Organization Elements (1.2.276.0.76.10.90011)
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             Diagnose Observation (1.2.276.0.76.10.4080)
            1. Entry
               Lateralität (1.2.276.0.76.10.90026)
            2. Entry
               Diagnosesicherheit (1.2.276.0.76.10.90027)
            3. Entry
               Author (Body) (1.2.276.0.76.10.90025)
              1. Header
                 CDA Person Elements (1.2.276.0.76.10.90010)
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                 CDA Organization Elements (1.2.276.0.76.10.90011)
            4. Entry
               Alter Beobachtung (1.2.276.0.76.10.4077)
            5. Entry
               Prognose Observation (1.2.276.0.76.10.4078)
            6. Entry
               Priorität Präferenz (1.2.276.0.76.10.4076)
              1. Entry
                 Author (Body) (1.2.276.0.76.10.90025)
                1. Header
                   CDA Person Elements (1.2.276.0.76.10.90010)
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                   CDA Organization Elements (1.2.276.0.76.10.90011)
            7. Entry
               Manifestation Observation (1.2.276.0.76.10.4093)
            8. Entry
               Etiology Observation (1.2.276.0.76.10.4094)
          3. Entry
             Priorität Präferenz (1.2.276.0.76.10.4076)
            1. Entry
               Author (Body) (1.2.276.0.76.10.90025)
              1. Header
                 CDA Person Elements (1.2.276.0.76.10.90010)
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      2. Section
         Entlassungsdiagnose (1.2.276.0.76.10.3027)
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           Diagnose Concern Act (1.2.276.0.76.10.4079)
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             Author (Body) (1.2.276.0.76.10.90025)
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               CDA Person Elements (1.2.276.0.76.10.90010)
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               CDA Organization Elements (1.2.276.0.76.10.90011)
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             Diagnose Observation (1.2.276.0.76.10.4080)
            1. Entry
               Lateralität (1.2.276.0.76.10.90026)
            2. Entry
               Diagnosesicherheit (1.2.276.0.76.10.90027)
            3. Entry
               Author (Body) (1.2.276.0.76.10.90025)
              1. Header
                 CDA Person Elements (1.2.276.0.76.10.90010)
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                 CDA Organization Elements (1.2.276.0.76.10.90011)
            4. Entry
               Alter Beobachtung (1.2.276.0.76.10.4077)
            5. Entry
               Prognose Observation (1.2.276.0.76.10.4078)
            6. Entry
               Priorität Präferenz (1.2.276.0.76.10.4076)
              1. Entry
                 Author (Body) (1.2.276.0.76.10.90025)
                1. Header
                   CDA Person Elements (1.2.276.0.76.10.90010)
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                   CDA Organization Elements (1.2.276.0.76.10.90011)
            7. Entry
               Manifestation Observation (1.2.276.0.76.10.4093)
            8. Entry
               Etiology Observation (1.2.276.0.76.10.4094)
          3. Entry
             Priorität Präferenz (1.2.276.0.76.10.4076)
            1. Entry
               Author (Body) (1.2.276.0.76.10.90025)
              1. Header
                 CDA Person Elements (1.2.276.0.76.10.90010)
              2. Header
                 CDA Organization Elements (1.2.276.0.76.10.90011)
      3. Section
         Medikation bei Einweisung (Historie) (1.2.276.0.76.10.3029)
        1. Entry
           Medikation (1.2.276.0.76.10.4022)
          1. Entry
             Author (Body) (1.2.276.0.76.10.90025)
            1. Header
               CDA Person Elements (1.2.276.0.76.10.90010)
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               CDA Organization Elements (1.2.276.0.76.10.90011)
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             RelatedEntity (Body) (1.2.276.0.76.10.90020)
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               CDA Person Elements (1.2.276.0.76.10.90010)
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             Einzeldosierungen (1.2.276.0.76.10.4023)
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             Dosierung Freitext (1.2.276.0.76.10.4024)
      4. Section
         Medikation bei Entlassung (1.2.276.0.76.10.3031)
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           Medikation (1.2.276.0.76.10.4022)
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             Author (Body) (1.2.276.0.76.10.90025)
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               CDA Person Elements (1.2.276.0.76.10.90010)
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               CDA Organization Elements (1.2.276.0.76.10.90011)
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             Einzeldosierungen (1.2.276.0.76.10.4023)
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             Dosierung Freitext (1.2.276.0.76.10.4024)
      5. Section
         Verabreichte Medikation während des Aufenthalts (1.2.276.0.76.10.3030)
        1. Entry
           Medikation (1.2.276.0.76.10.4022)
          1. Entry
             Author (Body) (1.2.276.0.76.10.90025)
            1. Header
               CDA Person Elements (1.2.276.0.76.10.90010)
            2. Header
               CDA Organization Elements (1.2.276.0.76.10.90011)
          2. Entry
             RelatedEntity (Body) (1.2.276.0.76.10.90020)
            1. Header
               CDA Person Elements (1.2.276.0.76.10.90010)
          3. Entry
             Einzeldosierungen (1.2.276.0.76.10.4023)
          4. Entry
             Dosierung Freitext (1.2.276.0.76.10.4024)
    28. Section
       Abschließende Bemerkungen (1.2.276.0.76.10.3034)
    29. Section
       Beilagen/Anhang (1.2.276.0.76.10.3037)
      1. Entry
         Eingebettetes Objekt Entry (1.2.276.0.76.10.4014)
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