1.2.276.0.76.3.1.261.1.10.3.20/static-2022-04-16T150015: Unterschied zwischen den Versionen

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<table xmlns="http://www.w3.org/1999/xhtml" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.276.0.76.3.1.261.1.10.3.20</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2022‑04‑16 15:00:15</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;">IntraoperativerBefundOperationsverlauf</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">Intraoperativer Befund und Operationsverlauf (DGUV)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beschreibung</th><td style="text-align: left;" colspan="3">Template CDA Section (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF)</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 1.2.276.0.76.3.1.261.1.10.3.20</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 id="assocsTable" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Assoziiert mit 2 Konzepte</td></tr><tr><td><div><table width="100%" border="0" cellspacing="1" cellpadding="3" class="artdecor " 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%;">dguvbbr-data&#8203;element3-120</td><td style="vertical-align: top;">[[File:Kyellow.png|14px]] OP-Befund und -Verlauf </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Operationsbericht  </td></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;">dguvbbr-data&#8203;element3-121</td><td style="vertical-align: top;" title="OP-Befund und -Verlauf / ">[[File:Kyellow.png|14px]] Freitext Intraoperativer Befund und Operationsverlauf </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Operationsbericht  </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>CDA Section </i> (2005‑09‑07) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">ad1bbr-</div></span></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" 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 cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:section<br xmlns="http://www.w3.org/1999/xhtml" /></span></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="">(Int...auf)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " 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;">dguvbbr-data&#8203;element3-120</td><td style="vertical-align: top;">[[File:Kyellow.png|14px]] OP-Befund und -Verlauf </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Operationsbericht  </td></tr></table></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@classCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">DOCSECT</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@moodCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:templateId<br xmlns="http://www.w3.org/1999/xhtml" /></span></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;"><span title="">(Int...auf)</span></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@root<br xmlns="http://www.w3.org/1999/xhtml" /></span></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">1.2.276.0.76.3.1.261.1.10.3.20</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:code<br xmlns="http://www.w3.org/1999/xhtml" /></span></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="">(Int...auf)</span></td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td rowspan="4" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">34848-2</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@codeSystem<br xmlns="http://www.w3.org/1999/xhtml" /></span></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 (LOINC)</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@codeSystemName<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">LOINC</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@displayName<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">Surgery Note</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:title<br xmlns="http://www.w3.org/1999/xhtml" /></span></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="">(Int...auf)</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 width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Elementinhalt muss "Intraoperativer Befund und Operationsverlauf" sein</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:text<br xmlns="http://www.w3.org/1999/xhtml" /></span></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="">(Int...auf)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " 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;">dguvbbr-data&#8203;element3-121</td><td style="vertical-align: top;" title="OP-Befund und -Verlauf / ">[[File:Kyellow.png|14px]] Freitext Intraoperativer Befund und Operationsverlauf </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Operationsbericht  </td></tr></table></td></tr></table></td></tr></table>
+
<table xmlns="http://www.w3.org/1999/xhtml" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.276.0.76.3.1.261.1.10.3.20</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2022‑04‑16 15:00:15</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;">IntraoperativerBefundOperationsverlauf</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">Intraoperativer Befund und Operationsverlauf (DGUV)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beschreibung</th><td style="text-align: left;" colspan="3">Template CDA Section (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF)</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 1.2.276.0.76.3.1.261.1.10.3.20</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 id="assocsTable" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Assoziiert mit 2 Konzepte</td></tr><tr><td><div><table width="100%" border="0" cellspacing="1" cellpadding="3" class="artdecor " 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%;">dguvbbr-data&#8203;element3-120</td><td style="vertical-align: top;">[[File:Kyellow.png|14px]] OP-Befund und -Verlauf </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Operationsbericht  </td></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;">dguvbbr-data&#8203;element3-121</td><td style="vertical-align: top;" title="OP-Befund und -Verlauf / ">[[File:Kyellow.png|14px]] Freitext Intraoperativer Befund und Operationsverlauf </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Operationsbericht  </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>CDA Section </i> (2005‑09‑07) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">ad1bbr-</div></span></td></tr><tr class="explabel " style="vertical-align: top;"><th class="" style="width: 20em; text-align: left;">Beispiel</th><td colspan="3" class="explabelblue"><table width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Beispiel</span></td></tr><tr><td><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">section</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">DOCSECT</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.3.1.261.1.10.3.20</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">34848-2</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Surgery Note</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">title</span><span class="ppsign">&gt;</span><span class="pptext">Intraoperativer Befund und Operationsverlauf</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">title</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">li</span><span class="ppsign">&gt;</span><span class="pptext">Rückenlage, Armtisch links, übliche OP-Feldvorbereitung mit Oberarmblutsperre die zu Beginn der Operation angelegt und aufgeblasen wird.</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">li</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">li</span><span class="ppsign">&gt;</span><span class="pptext">Es erfolgt der typische Zugang radiodorsal. Präparation durch Subkutis und dann Faszie bis auf die Fraktur.</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">li</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">li</span><span class="ppsign">&gt;</span><span class="pptext">Hier zeigt sich viel zerrissenes Gewebe. Die Fraktur wird vorsichtig von radial dargestellt, <br />            um ein Haken werden eingesetzt. Nun wird die Fraktur reponiert <br />            und dann eine 7 Loch LCDC Platte aufgelegt. Übliche Fixation <br />            mit exzentrisch besetzten Zugschrauben dann mit Kopf Verriegelungsschrauben. <br />            Alle Schrauben haben einen sehr guten Halt. Spülung Bildwandlerdokumentation. In mehreren Ebenen schichtweiser Wundverschluss. <br />            Die Luxation des distalen Radioulnargelenkes wird nochmals klinisch wie unter Durchleuchtung untersucht. Hier zeigt sich wenig Dehiszenz und keine Reluxationsneigung nach erfolgter Osteosynthese, <br />            sodass eine direkte Attestierung durch offene Darstellung des Gelenkes oder Kirschnerdrahtfixierung nicht erforderlich ist</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">li</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">section</span><span class="ppsign">&gt;</span></span></span></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" 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 cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:section<br xmlns="http://www.w3.org/1999/xhtml" /></span></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="">(Int...auf)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " 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;">dguvbbr-data&#8203;element3-120</td><td style="vertical-align: top;">[[File:Kyellow.png|14px]] OP-Befund und -Verlauf </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Operationsbericht  </td></tr></table></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@classCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">DOCSECT</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@moodCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:templateId<br xmlns="http://www.w3.org/1999/xhtml" /></span></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;"><span title="">(Int...auf)</span></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@root<br xmlns="http://www.w3.org/1999/xhtml" /></span></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">1.2.276.0.76.3.1.261.1.10.3.20</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:code<br xmlns="http://www.w3.org/1999/xhtml" /></span></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="">(Int...auf)</span></td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td rowspan="4" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">34848-2</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@codeSystem<br xmlns="http://www.w3.org/1999/xhtml" /></span></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 (LOINC)</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@codeSystemName<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">LOINC</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@displayName<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">Surgery Note</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:title<br xmlns="http://www.w3.org/1999/xhtml" /></span></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="">(Int...auf)</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 width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Elementinhalt muss "Intraoperativer Befund und Operationsverlauf" sein</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:text<br xmlns="http://www.w3.org/1999/xhtml" /></span></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="">(Int...auf)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " 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;">dguvbbr-data&#8203;element3-121</td><td style="vertical-align: top;" title="OP-Befund und -Verlauf / ">[[File:Kyellow.png|14px]] Freitext Intraoperativer Befund und Operationsverlauf </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Operationsbericht  </td></tr></table></td></tr></table></td></tr></table>
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<!--2b9e1a5c30b4d2134f5668677d845f3fbc322ca0-->

Aktuelle Version vom 8. Juli 2022, 18:25 Uhr

Id1.2.276.0.76.3.1.261.1.10.3.20Gültigkeit2022‑04‑16 15:00:15
StatusKyellow.png EntwurfVersions-Label
NameIntraoperativerBefundOperationsverlaufBezeichnungIntraoperativer Befund und Operationsverlauf (DGUV)
BeschreibungTemplate CDA Section (Prototyp, direkt abgeleitet aus POCD_RM000040 MIF)
KontextElternknoten des Template-Element mit Id 1.2.276.0.76.3.1.261.1.10.3.20
KlassifikationCDA Section level template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Assoziiert mit
Assoziiert mit 2 Konzepte
IdNameDatensatz
dguvbbr-data​element3-120Kyellow.png OP-Befund und -Verlauf Kyellow.png Operationsbericht
dguvbbr-data​element3-121Kyellow.png Freitext Intraoperativer Befund und Operationsverlauf Kyellow.png Operationsbericht
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
Beispiel
Beispiel
<hl7:section classCode="DOCSECT" moodCode="EVN">
  <hl7:templateId root="1.2.276.0.76.3.1.261.1.10.3.20"/>  <hl7:code code="34848-2" codeSystem="2.16.840.1.113883.6.1" displayName="Surgery Note"/>  <hl7:title>Intraoperativer Befund und Operationsverlauf</hl7:title>  <hl7:text>
    <hl7:li>Rückenlage, Armtisch links, übliche OP-Feldvorbereitung mit Oberarmblutsperre die zu Beginn der Operation angelegt und aufgeblasen wird.</hl7:li>    <hl7:li>Es erfolgt der typische Zugang radiodorsal. Präparation durch Subkutis und dann Faszie bis auf die Fraktur.</hl7:li>    <hl7:li>Hier zeigt sich viel zerrissenes Gewebe. Die Fraktur wird vorsichtig von radial dargestellt,
um ein Haken werden eingesetzt. Nun wird die Fraktur reponiert
und dann eine 7 Loch LCDC Platte aufgelegt. Übliche Fixation
mit exzentrisch besetzten Zugschrauben dann mit Kopf Verriegelungsschrauben.
Alle Schrauben haben einen sehr guten Halt. Spülung Bildwandlerdokumentation. In mehreren Ebenen schichtweiser Wundverschluss.
Die Luxation des distalen Radioulnargelenkes wird nochmals klinisch wie unter Durchleuchtung untersucht. Hier zeigt sich wenig Dehiszenz und keine Reluxationsneigung nach erfolgter Osteosynthese,
sodass eine direkte Attestierung durch offene Darstellung des Gelenkes oder Kirschnerdrahtfixierung nicht erforderlich ist</hl7:li>  </hl7:text></hl7:section>
ItemDTKardKonfBeschreibungLabel
hl7:section
(Int...auf)
 
Target.png
dguvbbr-data​element3-120Kyellow.png OP-Befund und -Verlauf Kyellow.png Operationsbericht
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.png@moodCode
cs0 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(Int...auf)
Treeblank.pngTreetree.png@root
uid1 … 1F1.2.276.0.76.3.1.261.1.10.3.20
Treetree.pnghl7:code
CE1 … 1M(Int...auf)
Treeblank.pngTreetree.png@code
CONF1 … 1F34848-2
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treeblank.pngTreetree.png@displayName
1 … 1FSurgery Note
Treetree.pnghl7:title
ST1 … 1M(Int...auf)
 CONF
Elementinhalt muss "Intraoperativer Befund und Operationsverlauf" sein
Treetree.pnghl7:text
SD.TEXT1 … 1M(Int...auf)
 
Target.png
dguvbbr-data​element3-121Kyellow.png Freitext Intraoperativer Befund und Operationsverlauf Kyellow.png Operationsbericht
Abgerufen von „https://wiki.hl7.de/index.php?title=1.2.276.0.76.3.1.261.1.10.3.20/static-2022-04-16T150015&oldid=78718“