cdapad:Pflegedokumentation-Section (Template): Unterschied zwischen den Versionen
(→Section: Pflegedokumentation) |
Hkadi (Diskussion | Beiträge) (→Section: Pflegedokumentation) |
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[[Datei:Pflegedokumentation_cda.png]] | [[Datei:Pflegedokumentation_cda.png]] | ||
| + | {| class="hl7table" | ||
| + | ! Lvl | ||
| + | ! RIM | ||
| + | ! Name | ||
| + | ! DT | ||
| + | ! Kard | ||
| + | ! Conf | ||
| + | ! Beschreibung | ||
| + | |||
| + | |- | ||
| + | |1 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |Pflegedokumentation | ||
| + | | | ||
| + | |null | ||
| + | |null | ||
| + | | | ||
| + | |||
| + | |- | ||
| + | |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 | ||
| + | |0..1 | ||
| + | |O | ||
| + | | | ||
| + | |||
| + | |- | ||
| + | |1 | ||
| + | |bgcolor="ffaaaa"|rel | ||
| + | |entry | ||
| + | | | ||
| + | |1..1 | ||
| + | |R | ||
| + | | | ||
| + | |||
| + | |- | ||
| + | |2 | ||
| + | |bgcolor="ffaaaa"|rel | ||
| + | |@typeCode | ||
| + | |CS CNE | ||
| + | |1..1 | ||
| + | |M | ||
| + | | | ||
| + | |||
| + | |- | ||
| + | |2 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |Pflegedokumentation | ||
| + | | | ||
| + | |0..* | ||
| + | |O | ||
| + | | | ||
| + | |||
| + | |- | ||
| + | |3 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |@classCode | ||
| + | |CS CNE | ||
| + | |1..1 | ||
| + | |M | ||
| + | |OBS | ||
| + | |||
| + | |- | ||
| + | |3 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |@moodCode | ||
| + | |CS CNE | ||
| + | |1..1 | ||
| + | |M | ||
| + | |EVN | ||
| + | |||
| + | |- | ||
| + | |3 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |code | ||
| + | |CW CWE | ||
| + | |0..1 | ||
| + | |O | ||
| + | | | ||
| + | |||
| + | |- | ||
| + | |3 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |text | ||
| + | |ED | ||
| + | |0..1 | ||
| + | |O | ||
| + | | | ||
| + | |||
| + | |- | ||
| + | |3 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |effectiveTime | ||
| + | |TS | ||
| + | |0..1 | ||
| + | |O | ||
| + | | | ||
| + | |||
| + | |- | ||
| + | |3 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |value | ||
| + | |ANY CWE | ||
| + | |0..1 | ||
| + | |O | ||
| + | | | ||
| + | |||
| + | |||
| + | |} | ||
Version vom 3. März 2014, 16:06 Uhr
Section: Pflegedokumentation
| Template-Metadaten | |
| Template-Typ | Section |
| Template ID | keine |
| generischeres Template | - |
| genutztes Templates | - |
| nutzende Templates | - |
| abgeleitete Templates | - |
| Schwester-Templates | - |
| generelle Beschreibung | Pflegedokumentation |
| allg. Erläuterung | Sektion Pflegedokumentation |
| Verhältnis zu IHE | neu |
| Ballotierungsstatus | in Abstimmung |
| Erweiterbarkeit | offen |
Die Pflegedokumentation wird in der Section „Pflegedokumentation“ festgehalten. Hier können Informationen zur Patientenpflege hinterlegt werden, welche eine Relevanz für das PalliativCareTeam haben.
| Lvl | RIM | Name | DT | Kard | Conf | Beschreibung |
|---|---|---|---|---|---|---|
| 1 | act | Pflegedokumentation | null | null | ||
| 1 | act | @classCode | CS CNE | 1..1 | M | DOCSECT |
| 1 | act | @moodCode | CS CNE | 1..1 | M | EVN |
| 1 | act | code | CD CWE | 0..1 | O | |
| 1 | rel | entry | 1..1 | R | ||
| 2 | rel | @typeCode | CS CNE | 1..1 | M | |
| 2 | act | Pflegedokumentation | 0..* | O | ||
| 3 | act | @classCode | CS CNE | 1..1 | M | OBS |
| 3 | act | @moodCode | CS CNE | 1..1 | M | EVN |
| 3 | act | code | CW CWE | 0..1 | O | |
| 3 | act | text | ED | 0..1 | O | |
| 3 | act | effectiveTime | TS | 0..1 | O | |
| 3 | act | value | ANY CWE | 0..1 | O |
|
Beispiel
<section>
<code code="Pflegedokumentation" codeSystem="LOINC" />
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<code xsi:type="CD" code="5.0" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="Pflegedokumentation"/>
<effectiveTime value="20140201" />
<value xsi:type="CD" code="4" codeSystem="1.2.276.0.76.3.1.81.4.6.5" codeSystemName="Problembereiche" displayName=”Ausscheidung”/>
<entryRelationship typeCode="COMP">
<!-- Neuer Eintrag -->
</entryRelationship>
</observation>
</entry>
</section>
