cdapad:Aufnahme-Section (Template): Unterschied zwischen den Versionen
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− | |bgcolor="ddddff"|generischeres Template || | + | |bgcolor="ddddff"|generischeres Template || - |
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− | |bgcolor="ddddff"|genutztes Templates || | + | |bgcolor="ddddff"|genutztes Templates || - |
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− | |bgcolor="ddddff"|nutzende Templates || | + | |bgcolor="ddddff"|nutzende Templates || - |
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− | |bgcolor="ddddff"|abgeleitete Templates || | + | |bgcolor="ddddff"|abgeleitete Templates || - |
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− | |bgcolor="ddddff"|Schwester-Templates || | + | |bgcolor="ddddff"|Schwester-Templates || - |
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− | |bgcolor="ddddff"|generelle Beschreibung|| | + | |bgcolor="ddddff"|generelle Beschreibung|| Aufnahme |
|- | |- | ||
− | |bgcolor="ddddff"|allg. Erläuterung|| | + | |bgcolor="ddddff"|allg. Erläuterung|| Sektion Aufnahme |
|- | |- | ||
− | |bgcolor="ddddff"|Verhältnis zu IHE|| | + | |bgcolor="ddddff"|Verhältnis zu IHE|| neu |
|- | |- | ||
− | |bgcolor="ddddff"|Ballotierungsstatus|| | + | |bgcolor="ddddff"|Ballotierungsstatus|| in Abstimmung |
|- | |- | ||
− | |bgcolor="ddddff"|Erweiterbarkeit|| offen | + | |bgcolor="ddddff"|Erweiterbarkeit|| offen |
|} | |} | ||
+ | [[Kategorie:CDA Section Level Template|Aufnahme]] | ||
+ | [[Kategorie:cdapad|Aufnahme]] | ||
+ | |||
+ | |||
+ | Alle Aufnahmen (Erstaufnahme, Notaufnahme, geplante Wiederaufnahme etc.) werden in der Sektion „Aufnahme“ festgehalten. Über den Abschnitt Aufnahme werden relevante alle relevanten Daten der Aufnahme des Patienten in ein System der palliativen Versorgung festgehalten. | ||
+ | |||
+ | ===Modell=== | ||
+ | [[Datei:Aufnahme_cda2.png|800px]] | ||
+ | |||
+ | ===Attribute=== | ||
+ | {| class="hl7table" | ||
+ | ! Lvl | ||
+ | ! RIM | ||
+ | ! Name | ||
+ | ! DT | ||
+ | ! Kard | ||
+ | ! Conf | ||
+ | ! Beschreibung | ||
+ | |||
+ | |- | ||
+ | |1 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |Aufnahme | ||
+ | | | ||
+ | | | ||
+ | | | ||
+ | |Die für die Aufnahme eines Patienten relevanten Daten werden in dieser Sektion ferstgehalten | ||
+ | |||
+ | |- | ||
+ | |1 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |@classCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | |DOCSECT | ||
+ | |||
+ | |- | ||
+ | |1 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |@moodCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | |EVN | ||
+ | |||
+ | |- | ||
+ | |1 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |code | ||
+ | |CD CWE | ||
+ | |1..1 | ||
+ | |R | ||
+ | |codeSystem="LOINC", code="52536" | ||
+ | |||
+ | |- | ||
+ | |1 | ||
+ | |bgcolor="ffaaaa"|rel | ||
+ | |entry | ||
+ | | | ||
+ | |0..* | ||
+ | |O | ||
+ | | | ||
+ | |||
+ | |- | ||
+ | |2 | ||
+ | |bgcolor="ffaaaa"|rel | ||
+ | |@typeCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | | | ||
+ | |||
+ | |- | ||
+ | |2 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |Aufnahme | ||
+ | | | ||
+ | |0..* | ||
+ | |O | ||
+ | |Pro Aufnahme des Patienten wird eine solche Observation angelegt | ||
+ | |||
+ | |- | ||
+ | |3 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |@classCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | |ENC | ||
+ | |||
+ | |- | ||
+ | |3 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |@moodCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | |EVN | ||
+ | |||
+ | |- | ||
+ | |3 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |code | ||
+ | |CD CWE | ||
+ | |1..1 | ||
+ | |R | ||
+ | |codeSystem="1.2.276.0.76.3.1.81.4.6.2", codeSystemName="Zuweisung als" code="[1-4]" (z. B. 1 = Geplante Erstaufnahme) | ||
+ | |||
+ | |- | ||
+ | |3 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |effectiveTime | ||
+ | |TS | ||
+ | |1..1 | ||
+ | |R | ||
+ | |Datum der Aufnahme | ||
+ | |||
+ | |- | ||
+ | |3 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |id | ||
+ | |Set<II> | ||
+ | |0..* | ||
+ | |O | ||
+ | |Identifier | ||
+ | |||
+ | |- | ||
+ | |3 | ||
+ | |bgcolor="ccffff"|part | ||
+ | |participant | ||
+ | | | ||
+ | |0..1 | ||
+ | |O | ||
+ | |Angabe des Zuweisenden Arztes/Organisation | ||
+ | |||
+ | |- | ||
+ | |3 | ||
+ | |bgcolor="ffaaaa"|rel | ||
+ | |entry | ||
+ | | | ||
+ | |0..* | ||
+ | |O | ||
+ | | | ||
+ | |||
+ | |- | ||
+ | |4 | ||
+ | |bgcolor="ffaaaa"|rel | ||
+ | |@typeCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | | | ||
+ | |||
+ | |- | ||
+ | |4 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |Mobilität | ||
+ | | | ||
+ | |0..1 | ||
+ | |O | ||
+ | |Angabe der Mobilität des Patienten | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |@classCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | |OBS | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |@moodCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | |EVN | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |code | ||
+ | |CD CWE | ||
+ | |1..1 | ||
+ | |R | ||
+ | |codeSystem="1.2.276.0.76.3.1.81.4.6.0", code="3.1" | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |value | ||
+ | |ANY CWE | ||
+ | |1..1 | ||
+ | |R | ||
+ | |codeSystem="1.2.276.0.76.3.1.81.4.6.3", codeSystemName="Mobilität", code=[1-7], z. B. code=1 --> gefähig | ||
+ | |||
+ | |- | ||
+ | |3 | ||
+ | |bgcolor="ffaaaa"|rel | ||
+ | |entry | ||
+ | | | ||
+ | |0..1 | ||
+ | |O | ||
+ | | | ||
+ | |||
+ | |- | ||
+ | |4 | ||
+ | |bgcolor="ffaaaa"|rel | ||
+ | |@typeCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | | | ||
+ | |||
+ | |- | ||
+ | |4 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |Prognose | ||
+ | | | ||
+ | |0..* | ||
+ | |O | ||
+ | |Prognose für den Patienten | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |@classCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | |OBS | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |@moodCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | |EVN | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |code | ||
+ | |CD CWE | ||
+ | |1..1 | ||
+ | |R | ||
+ | ||codeSystem="1.2.276.0.76.3.1.81.4.6.0", code="3.2" | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |text | ||
+ | |ED | ||
+ | |1..1 | ||
+ | |O | ||
+ | |Freitext zur Prognose | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |value | ||
+ | |ANY CWE | ||
+ | |0..1 | ||
+ | |R | ||
+ | |Angabe des Codesystems für "Prognose" und Angabe der Prognose innerhalb des angegebenen Codesystems | ||
+ | |||
+ | |- | ||
+ | |3 | ||
+ | |bgcolor="ffaaaa"|rel | ||
+ | |entry | ||
+ | | | ||
+ | |0..1 | ||
+ | |O | ||
+ | | | ||
+ | |||
+ | |- | ||
+ | |4 | ||
+ | |bgcolor="ffaaaa"|rel | ||
+ | |@typeCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | | | ||
+ | |||
+ | |- | ||
+ | |4 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |ErkrankungsrelevanteBehandlung | ||
+ | | | ||
+ | |0..* | ||
+ | |O | ||
+ | |Beschreibt erkrankungsrelevante Behandlungen | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |@classCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | |PROC | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |@moodCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | |EVN | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |code | ||
+ | |CD CWE | ||
+ | |1..1 | ||
+ | |R | ||
+ | ||codeSystem="1.2.276.0.76.3.1.81.4.6.0", code="3.3" | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |text | ||
+ | |ED | ||
+ | |1..1 | ||
+ | |R | ||
+ | |Freitext | ||
+ | |||
+ | |- | ||
+ | |3 | ||
+ | |bgcolor="ffaaaa"|rel | ||
+ | |entry | ||
+ | | | ||
+ | |0..1 | ||
+ | |O | ||
+ | | | ||
+ | |||
+ | |- | ||
+ | |4 | ||
+ | |bgcolor="ffaaaa"|rel | ||
+ | |@typeCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | | | ||
+ | |||
+ | |- | ||
+ | |4 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |BesondererAufwandMit | ||
+ | | | ||
+ | |0..* | ||
+ | |O | ||
+ | |Angaben über mögliche Dinge mit denen der Patient besonderen Aufwand hat | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |@classCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | |OBS | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |@moodCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | |EVN | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |code | ||
+ | |CD CWE | ||
+ | |1..1 | ||
+ | |R | ||
+ | ||codeSystem="1.2.276.0.76.3.1.81.4.6.0", code="3.4" | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |text | ||
+ | |ED | ||
+ | |1..1 | ||
+ | |R | ||
+ | |Freitext | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |value | ||
+ | |ANY CWE | ||
+ | |0..1 | ||
+ | |O | ||
+ | |Angabe über Codesystem, falls vorhanden | ||
+ | |||
+ | |- | ||
+ | |3 | ||
+ | |bgcolor="ffaaaa"|rel | ||
+ | |entry | ||
+ | | | ||
+ | |0..1 | ||
+ | |O | ||
+ | | | ||
+ | |||
+ | |- | ||
+ | |4 | ||
+ | |bgcolor="ffaaaa"|rel | ||
+ | |@typeCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | | | ||
+ | |||
+ | |- | ||
+ | |4 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |PatientTherapieWuensche | ||
+ | | | ||
+ | |0..* | ||
+ | |O | ||
+ | |Wünsche des Patienten bzgl. der Therapie | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |@classCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | |OBS | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |@moodCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | |EVN | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |code | ||
+ | |CD CWE | ||
+ | |1..1 | ||
+ | |R | ||
+ | ||codeSystem="1.2.276.0.76.3.1.81.4.6.0", code="3.5" | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |text | ||
+ | |ED | ||
+ | |1..1 | ||
+ | |R | ||
+ | |Freitext | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |value | ||
+ | |ANY CWE | ||
+ | |0..1 | ||
+ | |O | ||
+ | |Angabe über Codesystem, falls vorhanden | ||
+ | |||
+ | |- | ||
+ | |3 | ||
+ | |bgcolor="ffaaaa"|rel | ||
+ | |entry | ||
+ | | | ||
+ | |0..1 | ||
+ | |O | ||
+ | | | ||
+ | |||
+ | |- | ||
+ | |4 | ||
+ | |bgcolor="ffaaaa"|rel | ||
+ | |@typeCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | | | ||
+ | |||
+ | |- | ||
+ | |4 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |Behandlungsziel | ||
+ | | | ||
+ | |0..* | ||
+ | |O | ||
+ | |Angaben zum Behandlungsziel | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |@classCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | |OBS | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |@moodCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | |GOL | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |code | ||
+ | |CD CWE | ||
+ | |1..1 | ||
+ | |R | ||
+ | ||codeSystem="1.2.276.0.76.3.1.81.4.6.0", code="3.6" | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |text | ||
+ | |ED | ||
+ | |1..1 | ||
+ | |R | ||
+ | |Freitext | ||
+ | |||
+ | |- | ||
+ | |5 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |value | ||
+ | |ANY CWE | ||
+ | |0..1 | ||
+ | |O | ||
+ | |Angabe über Codesystem, falls vorhanden | ||
+ | |||
+ | |} | ||
+ | |||
+ | === Katalog "Zuweisung als" (OID 1.2.276.0.76.3.1.81.4.6.2) === | ||
+ | |||
+ | {| class="wikitable" | ||
+ | |- | ||
+ | ! Code | ||
+ | ! Beschreibung | ||
+ | |||
+ | |- | ||
+ | | 1 | ||
+ | || Geplante Erstaufnahme | ||
+ | |||
+ | |- | ||
+ | | 2 | ||
+ | ||Notaufnahme | ||
+ | |||
+ | |- | ||
+ | | 3 | ||
+ | ||Geplante Wiederaufnahme | ||
+ | |||
+ | |- | ||
+ | | 4 | ||
+ | ||Sonstige | ||
+ | |||
+ | |} | ||
+ | |||
+ | === Katalog "Mobilität" (OID 1.2.276.0.76.3.1.81.4.6.3) === | ||
− | + | {| class="wikitable" | |
− | + | |- | |
+ | ! Code | ||
+ | ! Beschreibung | ||
+ | |||
+ | |- | ||
+ | | 1 | ||
+ | || Geh fähig | ||
+ | |||
+ | |- | ||
+ | | 2 | ||
+ | ||Rollator | ||
+ | |||
+ | |- | ||
+ | | 3 | ||
+ | ||Rollstuhl | ||
+ | |||
+ | |- | ||
+ | | 4 | ||
+ | ||Nachtstuhl | ||
+ | |||
+ | |} | ||
+ | |||
+ | ===Beispiel=== | ||
+ | <syntaxhighlight lang="xml"> | ||
+ | <section> | ||
+ | <code code="52536-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Admission Information"/> | ||
+ | <entry typeCode="DRIV"> | ||
+ | <observation classCode="OBS" moodCode="EVN"> | ||
+ | <code xsi:type="CD" code="3.0" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="Aufnahme"/> | ||
+ | <effectiveTime value="20140201"/> | ||
+ | <value xsi:type="CD" code="1" codeSystem="1.2.276.0.76.3.1.81.4.6.2" codeSystemName="Zuweisung als" displayName="Geplante Erstaufnahme"/> | ||
+ | <participant typeCode="REF"> | ||
+ | <participantRole classCode="CAREGIVER"> | ||
+ | <id extension="123 " root="xxx " /> | ||
+ | <playingEntity> | ||
+ | <name> | ||
+ | <given>Notarzt Dr. Max</given> | ||
+ | <family>Mustermann</family> | ||
+ | </name> | ||
+ | </playingEntity> | ||
+ | </participantRole> | ||
+ | </participant> | ||
+ | <entryRelationship typeCode="COMP"> | ||
+ | <observation classCode="OBS" moodCode="EVN"> | ||
+ | <code xsi:type="CD" code="xxx" codeSystem="xxx" codeSystemName="xxx" displayName="Mobilität"/> | ||
+ | <value xsi:type="CD" code="4" codeSystem="1.2.276.0.76.3.1.81.4.6.3" codeSystemName="Mobilitaet" displayName="Nachtstuhl"/> | ||
+ | </observation> | ||
+ | </entryRelationship> | ||
+ | <entryRelationship typeCode="COMP"> | ||
+ | <observation classCode="OBS" moodCode="EVN"> | ||
+ | <code xsi:type="CD" code="3.1" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="Prognose"/> | ||
+ | <text> | ||
+ | Text bwz. Kommentare, falls vorhanden | ||
+ | </text> | ||
+ | </observation> | ||
+ | </entryRelationship> | ||
+ | <entryRelationship typeCode="COMP"> | ||
+ | <observation classCode="OBS" moodCode="EVN"> | ||
+ | <code xsi:type="CD" code="3.4" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="Besonderer Aufwand mit"/> | ||
+ | <text> | ||
+ | Text bzw. Kommentare, falls vorhanden | ||
+ | </text> | ||
+ | </observation> | ||
+ | </entryRelationship> | ||
+ | <entryRelationship typeCode="COMP"> | ||
+ | <observation classCode="OBS" moodCode="EVN"> | ||
+ | <code xsi:type="CD" code="3.5" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="PatientenTherapieWuensche"/> | ||
+ | <text> | ||
+ | Text bzw. Kommentare, falls vorhanden | ||
+ | </text> | ||
+ | </observation> | ||
+ | </entryRelationship> | ||
+ | <entryRelationship typeCode="COMP"> | ||
+ | <observation classCode="OBS" moodCode="EVN"> | ||
+ | <code xsi:type="CD" code="3.6" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="Behandlungsziel"/> | ||
+ | <text> | ||
+ | Text bzw. Kommentare, falls vorhanden | ||
+ | </text> | ||
+ | </observation> | ||
+ | </entryRelationship> | ||
+ | <entryRelationship typeCode="COMP"> | ||
+ | <procedure classCode="PROC" moodCode="EVN"> | ||
+ | <code xsi:type="CD" code="3.3" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="ErkrankungsrelevanteBehandlung"/> | ||
+ | <text> | ||
+ | Text bzw. Kommentare, falls vorhanden | ||
+ | </text> | ||
+ | </procedure> | ||
+ | </entryRelationship> | ||
+ | <entryRelationship typeCode="COMP"> | ||
+ | <!-- Neuer Eintrag --> | ||
+ | </entryRelationship> | ||
+ | </observation> | ||
+ | </entry> | ||
+ | </section> | ||
+ | </syntaxhighlight> |
Aktuelle Version vom 17. Juni 2014, 14:18 Uhr
Inhaltsverzeichnis
Section: Aufnahme
Template-Metadaten | |
Template-Typ | Section |
Template ID | - |
generischeres Template | - |
genutztes Templates | - |
nutzende Templates | - |
abgeleitete Templates | - |
Schwester-Templates | - |
generelle Beschreibung | Aufnahme |
allg. Erläuterung | Sektion Aufnahme |
Verhältnis zu IHE | neu |
Ballotierungsstatus | in Abstimmung |
Erweiterbarkeit | offen |
Alle Aufnahmen (Erstaufnahme, Notaufnahme, geplante Wiederaufnahme etc.) werden in der Sektion „Aufnahme“ festgehalten. Über den Abschnitt Aufnahme werden relevante alle relevanten Daten der Aufnahme des Patienten in ein System der palliativen Versorgung festgehalten.
Modell
Attribute
Lvl | RIM | Name | DT | Kard | Conf | Beschreibung |
---|---|---|---|---|---|---|
1 | act | Aufnahme | Die für die Aufnahme eines Patienten relevanten Daten werden in dieser Sektion ferstgehalten | |||
1 | act | @classCode | CS CNE | 1..1 | M | DOCSECT |
1 | act | @moodCode | CS CNE | 1..1 | M | EVN |
1 | act | code | CD CWE | 1..1 | R | codeSystem="LOINC", code="52536" |
1 | rel | entry | 0..* | O | ||
2 | rel | @typeCode | CS CNE | 1..1 | M | |
2 | act | Aufnahme | 0..* | O | Pro Aufnahme des Patienten wird eine solche Observation angelegt | |
3 | act | @classCode | CS CNE | 1..1 | M | ENC |
3 | act | @moodCode | CS CNE | 1..1 | M | EVN |
3 | act | code | CD CWE | 1..1 | R | codeSystem="1.2.276.0.76.3.1.81.4.6.2", codeSystemName="Zuweisung als" code="[1-4]" (z. B. 1 = Geplante Erstaufnahme) |
3 | act | effectiveTime | TS | 1..1 | R | Datum der Aufnahme |
3 | act | id | Set<II> | 0..* | O | Identifier |
3 | part | participant | 0..1 | O | Angabe des Zuweisenden Arztes/Organisation | |
3 | rel | entry | 0..* | O | ||
4 | rel | @typeCode | CS CNE | 1..1 | M | |
4 | act | Mobilität | 0..1 | O | Angabe der Mobilität des Patienten | |
5 | act | @classCode | CS CNE | 1..1 | M | OBS |
5 | act | @moodCode | CS CNE | 1..1 | M | EVN |
5 | act | code | CD CWE | 1..1 | R | codeSystem="1.2.276.0.76.3.1.81.4.6.0", code="3.1" |
5 | act | value | ANY CWE | 1..1 | R | codeSystem="1.2.276.0.76.3.1.81.4.6.3", codeSystemName="Mobilität", code=[1-7], z. B. code=1 --> gefähig |
3 | rel | entry | 0..1 | O | ||
4 | rel | @typeCode | CS CNE | 1..1 | M | |
4 | act | Prognose | 0..* | O | Prognose für den Patienten | |
5 | act | @classCode | CS CNE | 1..1 | M | OBS |
5 | act | @moodCode | CS CNE | 1..1 | M | EVN |
5 | act | code | CD CWE | 1..1 | R | codeSystem="1.2.276.0.76.3.1.81.4.6.0", code="3.2" |
5 | act | text | ED | 1..1 | O | Freitext zur Prognose |
5 | act | value | ANY CWE | 0..1 | R | Angabe des Codesystems für "Prognose" und Angabe der Prognose innerhalb des angegebenen Codesystems |
3 | rel | entry | 0..1 | O | ||
4 | rel | @typeCode | CS CNE | 1..1 | M | |
4 | act | ErkrankungsrelevanteBehandlung | 0..* | O | Beschreibt erkrankungsrelevante Behandlungen | |
5 | act | @classCode | CS CNE | 1..1 | M | PROC |
5 | act | @moodCode | CS CNE | 1..1 | M | EVN |
5 | act | code | CD CWE | 1..1 | R | codeSystem="1.2.276.0.76.3.1.81.4.6.0", code="3.3" |
5 | act | text | ED | 1..1 | R | Freitext |
3 | rel | entry | 0..1 | O | ||
4 | rel | @typeCode | CS CNE | 1..1 | M | |
4 | act | BesondererAufwandMit | 0..* | O | Angaben über mögliche Dinge mit denen der Patient besonderen Aufwand hat | |
5 | act | @classCode | CS CNE | 1..1 | M | OBS |
5 | act | @moodCode | CS CNE | 1..1 | M | EVN |
5 | act | code | CD CWE | 1..1 | R | codeSystem="1.2.276.0.76.3.1.81.4.6.0", code="3.4" |
5 | act | text | ED | 1..1 | R | Freitext |
5 | act | value | ANY CWE | 0..1 | O | Angabe über Codesystem, falls vorhanden |
3 | rel | entry | 0..1 | O | ||
4 | rel | @typeCode | CS CNE | 1..1 | M | |
4 | act | PatientTherapieWuensche | 0..* | O | Wünsche des Patienten bzgl. der Therapie | |
5 | act | @classCode | CS CNE | 1..1 | M | OBS |
5 | act | @moodCode | CS CNE | 1..1 | M | EVN |
5 | act | code | CD CWE | 1..1 | R | codeSystem="1.2.276.0.76.3.1.81.4.6.0", code="3.5" |
5 | act | text | ED | 1..1 | R | Freitext |
5 | act | value | ANY CWE | 0..1 | O | Angabe über Codesystem, falls vorhanden |
3 | rel | entry | 0..1 | O | ||
4 | rel | @typeCode | CS CNE | 1..1 | M | |
4 | act | Behandlungsziel | 0..* | O | Angaben zum Behandlungsziel | |
5 | act | @classCode | CS CNE | 1..1 | M | OBS |
5 | act | @moodCode | CS CNE | 1..1 | M | GOL |
5 | act | code | CD CWE | 1..1 | R | codeSystem="1.2.276.0.76.3.1.81.4.6.0", code="3.6" |
5 | act | text | ED | 1..1 | R | Freitext |
5 | act | value | ANY CWE | 0..1 | O | Angabe über Codesystem, falls vorhanden |
Katalog "Zuweisung als" (OID 1.2.276.0.76.3.1.81.4.6.2)
Code | Beschreibung |
---|---|
1 | Geplante Erstaufnahme |
2 | Notaufnahme |
3 | Geplante Wiederaufnahme |
4 | Sonstige |
Katalog "Mobilität" (OID 1.2.276.0.76.3.1.81.4.6.3)
Code | Beschreibung |
---|---|
1 | Geh fähig |
2 | Rollator |
3 | Rollstuhl |
4 | Nachtstuhl |
Beispiel
<section>
<code code="52536-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Admission Information"/>
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<code xsi:type="CD" code="3.0" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="Aufnahme"/>
<effectiveTime value="20140201"/>
<value xsi:type="CD" code="1" codeSystem="1.2.276.0.76.3.1.81.4.6.2" codeSystemName="Zuweisung als" displayName="Geplante Erstaufnahme"/>
<participant typeCode="REF">
<participantRole classCode="CAREGIVER">
<id extension="123 " root="xxx " />
<playingEntity>
<name>
<given>Notarzt Dr. Max</given>
<family>Mustermann</family>
</name>
</playingEntity>
</participantRole>
</participant>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<code xsi:type="CD" code="xxx" codeSystem="xxx" codeSystemName="xxx" displayName="Mobilität"/>
<value xsi:type="CD" code="4" codeSystem="1.2.276.0.76.3.1.81.4.6.3" codeSystemName="Mobilitaet" displayName="Nachtstuhl"/>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<code xsi:type="CD" code="3.1" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="Prognose"/>
<text>
Text bwz. Kommentare, falls vorhanden
</text>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<code xsi:type="CD" code="3.4" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="Besonderer Aufwand mit"/>
<text>
Text bzw. Kommentare, falls vorhanden
</text>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<code xsi:type="CD" code="3.5" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="PatientenTherapieWuensche"/>
<text>
Text bzw. Kommentare, falls vorhanden
</text>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<code xsi:type="CD" code="3.6" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="Behandlungsziel"/>
<text>
Text bzw. Kommentare, falls vorhanden
</text>
</observation>
</entryRelationship>
<entryRelationship typeCode="COMP">
<procedure classCode="PROC" moodCode="EVN">
<code xsi:type="CD" code="3.3" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="ErkrankungsrelevanteBehandlung"/>
<text>
Text bzw. Kommentare, falls vorhanden
</text>
</procedure>
</entryRelationship>
<entryRelationship typeCode="COMP">
<!-- Neuer Eintrag -->
</entryRelationship>
</observation>
</entry>
</section>