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| − | <table class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="border:1px solid #C0C0C0; width: 107pt;" align="left"><strong>Template </strong></th><td align="left" style="background-color: #F6F3EE">Pflegediagnose Entry<i> / PflegediagnoseEntry</i></td></tr><tr><th align="left">Id</th><td align="left" style="background-color: #F6F3EE">1.2.276.0.76.10.4001</td></tr><tr><th align="left">Klassifikation</th><td align="left" style="background-color: #F6F3EE">CDA entry level template</td></tr><tr><th align="left">Kontext</th><td align="left" style="background-color: #F6F3EE">Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4001</td></tr><tr><th align="left"> Version </th><td align="left" style="background-color: #F6F3EE"> gültig ab 2013‑01‑23 Status In Entwicklung</td></tr><tr valign="top"><th align="left">Offen/Geschlossen</th><td style="background-color: #F6F3EE">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr valign="top"><th align="left">Beschreibung</th><td> <span class="xforms-group" id="xf-242"> <span class="fr-accordion-lnf xforms-group" id="xf-303$fr-accordion-group"> <span class="xforms-group" id="xf-303$xf-794">Mit diesem entry template werden maschinenlesbare pflegerische Zustandsbeschreibungen transportiert. Diese Zustandsbeschreibungen können in Form von Pflegediagnosen oder Pflegeproblemen vorliegen. Gemein ist beiden Formen, dass Pflege aufgrund dieser Zustände aktiv wird. Das bedeutet, dass eine Pflegediagnose zumeist eine Pflegeintervention nach sich zieht. Folgende internationale Klassifikationen stehen (kostenpflichtig) zur Verfügung: International Classification of Nursing Pracitce (ICNP), NANDA-I Diagnoses, International Classification of Functioning, Disability and Health (ICF), Clinical Care Classification (CCC). Auf nationaler Ebene können neben den Übersetzungen der internationalen Klassifikationen folgende Terminologien (ggf. kostenplfichtig) genutzt werden: apenio bzw. European Nursing Care Pathways (ENP). <br clear="none"> </span> </span> </span> </td></tr><tr class="explabel" valign="top"><td>Beispiel</td><td class="explabelblue"><tt><div><span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">act</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">ACT</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">></span><div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.4001</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">active</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">></span><div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">></span><div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.999.888.777.22.77.10.19</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">CAREDX</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.342</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">value</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">A01.5</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.236</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Beeinträchtigung der körperlichen Mobilität</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">Clinical Care Classification</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">></span></div> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">></span></div><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">act</span><span class="ppsign">></span></div></tt></td></tr><tr class="explabel" valign="top"><td>Beispiel</td><td class="explabelblue"><tt><div><span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">act</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">ACT</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">></span><div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.4001</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">active</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">></span><div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">></span><div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.999.888.777.22.77.10.19</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">CAREDX</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.342</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div><div> <span class="ppsign"><</span><span class="ppnamespace"></span><span class="ppelement">value</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">10001219</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.97</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Impaired Mobility</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">Intermational Classification of Nursing Practice</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span><div></div></div> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">></span></div> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">></span></div><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">act</span><span class="ppsign">></span></div></tt></td></tr><tr><td colspan="2" class="tabtab"><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="6" style="background: transparent;"><tr><th align="left" width="1%">Item</th><th align="left" width="1%">DT</th><th align="left" width="1%">Card</th><th align="left" width="1%">Conf</th><th align="left">Desc</th><th align="left" width="1%">Label</th></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:act<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong></strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>0 .. *</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>classCode<br></strong></tt></td></tr></table></td><td></td><td>1 .. 1</td><td>F</td><td colspan="2">ACT</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>moodCode<br></strong></tt></td></tr></table></td><td></td><td>1 .. 1</td><td>F</td><td colspan="2">EVN</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:templateId<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>II</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1 .. 1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>root<br></strong></tt></td></tr></table></td><td></td><td>1 .. 1</td><td>F</td><td colspan="2">1.2.276.0.76.10.4001</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:statusCode<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>CS</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1 .. 1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>code<br></strong></tt></td></tr></table></td><td></td><td>1 .. 1</td><td>F</td><td colspan="2">active</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:entryRelationship<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong></strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1 .. 1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:observation<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong></strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1 .. 1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:templateId<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong></strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1 .. 1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>root<br></strong></tt></td></tr></table></td><td></td><td>1 .. 1</td><td>F</td><td colspan="2">2.999.888.777.22.77.10.19</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:code<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>CE</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1 .. 1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>code<br></strong></tt></td></tr></table></td><td></td><td>1 .. 1</td><td>F</td><td colspan="2">CAREDX</td></tr><tr><td><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td>@<tt><strong>codeSystem<br></strong></tt></td></tr></table></td><td></td><td>1 .. 1</td><td>F</td><td colspan="2">1.2.276.0.76.5.342</td></tr><tr bgcolor="#FFEAEA"><td style="vertical-align: top;"><table class="artdecor" border="0" cellpadding="1" style="background: transparent;"><tr><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treeblank.png|15px]]</td><td valign="top">[[Datei:Treetree.png|15px]]</td><td><tt><strong>hl7:value<br></strong></tt></td></tr></table></td><td style="vertical-align: top;"><strong>CD</strong></td><td style="vertical-align: top;"><span style="color: black;"><strong>1 .. 1</strong></span></td><td style="vertical-align: top;"><span style="color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td style="background-color: white"></td><td class="conf" valign="top">CONF </td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr valign="top"><td>@codeSystem muss "2.16.840.1.113883.6.97" sein</td></tr><tr valign="top"><td>oder</td></tr><tr valign="top"><td>@codeSystem muss "2.16.840.1.113883.6.204" sein</td></tr><tr valign="top"><td>oder</td></tr><tr valign="top"><td>@codeSystem muss "2.16.840.1.113883.6.254" sein</td></tr><tr valign="top"><td>oder</td></tr><tr valign="top"><td>@codeSystem muss "2.16.840.1.113883.6.236" sein</td></tr><tr valign="top"><td>oder</td></tr><tr valign="top"><td>@codeSystem muss "1.2.276.0.76.3.1.125.1" sein</td></tr><tr valign="top"><td>oder</td></tr><tr valign="top"><td>@codeSystem muss "1.2.276.0.76.5.407" sein</td></tr></table></td></tr></table></td></tr></table>
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