1.2.276.0.76.10.4001/static-2013-01-23T000000: Unterschied zwischen den Versionen

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<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="border:1px solid #C0C0C0; width: 107pt; text-align: left;"><strong>Template </strong></th><td xmlns="" style="text-align: left; background-color: #F6F3EE">Pflegediagnose Entry<i> / PflegediagnoseEntry</i></td></tr><tr><th style="text-align: left;">Id</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">1.2.276.0.76.10.4001</td></tr><tr><th style="text-align: left;">Klassifikation</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">CDA entry level template</td></tr><tr><th style="text-align: left;">Kontext</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4001</td></tr><tr><th style="text-align: left;"> Version </th><td xmlns="" style="text-align: left; background-color: #F6F3EE"> gültig ab 2013‑01‑23 Status In Entwicklung</td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Offen/Geschlossen</th><td xmlns="" style="background-color: #F6F3EE">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Beschreibung</th><td xmlns="">
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<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="border:1px solid #C0C0C0; width: 107pt; text-align: left;"><strong>Template </strong></th><td xmlns="" style="text-align: left; background-color: #F6F3EE">Pflegediagnose Entry<i> / PflegediagnoseEntry</i></td></tr><tr><th style="text-align: left;">Id</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">1.2.276.0.76.10.4001</td></tr><tr><th style="text-align: left;">Klassifikation</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">CDA entry level template</td></tr><tr><th style="text-align: left;">Kontext</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4001</td></tr><tr><th style="text-align: left;"> Version </th><td xmlns="" style="text-align: left; background-color: #F6F3EE"> gültig ab 2013‑01‑23 Status In Entwicklung</td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Offen/Geschlossen</th><td xmlns="" style="background-color: #F6F3EE">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Beschreibung</th><td xmlns="">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).</td></tr><tr class="explabel" style="vertical-align: top;"><td xmlns="">Beispiel</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span><br /></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span><br /></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">observation</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span><br /></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span><br /></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span><br /></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">act</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr class="explabel" style="vertical-align: top;"><td xmlns="">Beispiel</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span><br /></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span><br /></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">observation</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span><br /></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span><br /></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span><br /></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">act</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr><td xmlns="" colspan="2" class="tabtab"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="6" style="background: transparent;"><tr><th style="width: 1%; text-align: left;">Item</th><th style="width: 1%; text-align: left;">DT</th><th style="width: 1%; text-align: left;">Kard</th><th style="width: 1%; text-align: left;">Konf</th><th style="text-align: left;">Beschreibung</th><th style="width: 1%; text-align: left;">Label</th></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:act<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml"></strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>0 .. *</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong></strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@classCode<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">ACT</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@moodCode<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">EVN</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">II</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>R</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@root<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">1.2.276.0.76.10.4001</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:statusCode<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">CS</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@code<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">active</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:entryRelationship<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml"></strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:observation<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml"></strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml"></strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@root<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">2.999.888.777.22.77.10.19</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:code<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">CE</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@code<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">CAREDX</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">1.2.276.0.76.5.342</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:value<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">CD</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td xmlns="" style="background-color: white"> </td><td xmlns="" style="vertical-align: top;" class="conf">CONF </td><td xmlns="" colspan="4"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td xmlns="">@codeSystem muss "2.16.840.1.113883.6.97" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystemName muss "International Classification of Nursing Practice (ICNP)" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">oder</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystem muss "2.16.840.1.113883.6.204" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystemName muss "NANDA-I Nursing Diagnosis" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">oder</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystem muss "2.16.840.1.113883.6.254" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystemName muss "International Classification of Functioning, Disability and Health (ICF)" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">oder</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystem muss "2.16.840.1.113883.6.236" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystemName muss "Clinical Care Classification (CCC)" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">oder</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystem muss "1.2.276.0.76.3.1.125.1" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystemName muss "apenio" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">oder</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystem muss "1.2.276.0.76.5.407" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystemName muss "European Nursing care pathways" sein</td></tr></table></td></tr></table></td></tr></table>
                    <span xmlns="http://www.w3.org/1999/xhtml" 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 />
 
                            </span>
 
                        </span>
 
                    </span>
 
                </td></tr><tr class="explabel" style="vertical-align: top;"><td xmlns="">Beispiel</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span><br /></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span><br /></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">observation</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span><br /></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span><br /></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span><br /></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">act</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr class="explabel" style="vertical-align: top;"><td xmlns="">Beispiel</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span><br /></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span><br /></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">observation</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span><br /></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span><br /></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span><br /></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">act</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr><td xmlns="" colspan="2" class="tabtab"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="6" style="background: transparent;"><tr><th style="width: 1%; text-align: left;">Item</th><th style="width: 1%; text-align: left;">DT</th><th style="width: 1%; text-align: left;">Kard</th><th style="width: 1%; text-align: left;">Konf</th><th style="text-align: left;">Beschreibung</th><th style="width: 1%; text-align: left;">Label</th></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:act<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml"></strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>0 .. *</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong></strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@classCode<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">ACT</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@moodCode<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">EVN</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">II</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>R</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@root<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">1.2.276.0.76.10.4001</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:statusCode<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">CS</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@code<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">active</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:entryRelationship<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml"></strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:observation<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml"></strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml"></strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@root<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">2.999.888.777.22.77.10.19</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:code<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">CE</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@code<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">CAREDX</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">1.2.276.0.76.5.342</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|15px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|15px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:value<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">CD</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(PflegediagnoseEntry)</td></tr><tr><td xmlns="" style="background-color: white"> </td><td xmlns="" style="vertical-align: top;" class="conf">CONF </td><td xmlns="" colspan="4"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td xmlns="">@codeSystem muss "2.16.840.1.113883.6.97" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystemName muss "International Classification of Nursing Practice (ICNP)" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">oder</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystem muss "2.16.840.1.113883.6.204" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystemName muss "NANDA-I Nursing Diagnosis" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">oder</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystem muss "2.16.840.1.113883.6.254" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystemName muss "International Classification of Functioning, Disability and Health (ICF)" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">oder</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystem muss "2.16.840.1.113883.6.236" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystemName muss "Clinical Care Classification (CCC)" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">oder</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystem muss "1.2.276.0.76.3.1.125.1" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystemName muss "apenio" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">oder</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystem muss "1.2.276.0.76.5.407" sein</td></tr><tr style="vertical-align: top;"><td xmlns="">@codeSystemName muss "European Nursing care pathways" sein</td></tr></table></td></tr></table></td></tr></table>
 

Version vom 7. Juni 2015, 15:03 Uhr

Template Pflegediagnose Entry / PflegediagnoseEntry
Id1.2.276.0.76.10.4001
KlassifikationCDA entry level template
KontextElternknoten des Template-Element mit Id 1.2.276.0.76.10.4001
Version gültig ab 2013‑01‑23 Status In Entwicklung
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
BeschreibungMit 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).
Beispiel<act classCode="ACT" moodCode="EVN">
  <templateId root="1.2.276.0.76.10.4001"/>
  <statusCode code="active"/>
  <entryRelationship>
    <observation>
      <templateId root="2.999.888.777.22.77.10.19"/>
      <code code="CAREDX" codeSystem="1.2.276.0.76.5.342"/>
      <value code="A01.5" codeSystem="2.16.840.1.113883.6.236" displayName="Beeinträchtigung der körperlichen Mobilität" codeSystemName="Clinical Care Classification"/>
    </observation>
  </entryRelationship>
</act>
Beispiel<act classCode="ACT" moodCode="EVN">
  <templateId root="1.2.276.0.76.10.4001"/>
  <statusCode code="active"/>
  <entryRelationship>
    <observation>
      <templateId root="2.999.888.777.22.77.10.19"/>
      <code code="CAREDX" codeSystem="1.2.276.0.76.5.342"/>
      <value code="10001219" codeSystem="2.16.840.1.113883.6.97" displayName="Impaired Mobility" codeSystemName="Intermational Classification of Nursing Practice"/>
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</act>
ItemDTKardKonfBeschreibungLabel
hl7:act
0 .. *(PflegediagnoseEntry)
Treetree.png@classCode
1 .. 1FACT
Treetree.png@moodCode
1 .. 1FEVN
Treetree.pnghl7:templateId
II1 .. 1R(PflegediagnoseEntry)
Treeblank.pngTreetree.png@root
1 .. 1F1.2.276.0.76.10.4001
Treetree.pnghl7:statusCode
CS1 .. 1M(PflegediagnoseEntry)
Treeblank.pngTreetree.png@code
1 .. 1Factive
Treetree.pnghl7:entryRelationship
1 .. 1M(PflegediagnoseEntry)
Treeblank.pngTreetree.pnghl7:observation
1 .. 1M(PflegediagnoseEntry)
Treeblank.pngTreeblank.pngTreetree.pnghl7:templateId
1 .. 1M(PflegediagnoseEntry)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
1 .. 1F2.999.888.777.22.77.10.19
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE1 .. 1M(PflegediagnoseEntry)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
1 .. 1FCAREDX
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 .. 1F1.2.276.0.76.5.342
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD1 .. 1M(PflegediagnoseEntry)
 CONF
@codeSystem muss "2.16.840.1.113883.6.97" sein
@codeSystemName muss "International Classification of Nursing Practice (ICNP)" sein
oder
@codeSystem muss "2.16.840.1.113883.6.204" sein
@codeSystemName muss "NANDA-I Nursing Diagnosis" sein
oder
@codeSystem muss "2.16.840.1.113883.6.254" sein
@codeSystemName muss "International Classification of Functioning, Disability and Health (ICF)" sein
oder
@codeSystem muss "2.16.840.1.113883.6.236" sein
@codeSystemName muss "Clinical Care Classification (CCC)" sein
oder
@codeSystem muss "1.2.276.0.76.3.1.125.1" sein
@codeSystemName muss "apenio" sein
oder
@codeSystem muss "1.2.276.0.76.5.407" sein
@codeSystemName muss "European Nursing care pathways" sein