1.2.276.0.76.10.4001/static-2013-01-23T000000: Unterschied zwischen den Versionen
ADbot (Diskussion | Beiträge) (Automated ADBot page content) |
ADbot (Diskussion | Beiträge) (Automated ADBot page content) |
||
| Zeile 1: | Zeile 1: | ||
| − | <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;"> Version </th><td xmlns="" style="text-align: left; background-color: #F6F3EE"> gültig ab 2013‑01‑23 Status [[Datei:Kyellow.png|16px]] In Entwicklung</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 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"><</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><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">entryRelationship</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">observation</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">act</span><span class="ppsign">></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"><</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><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">entryRelationship</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">observation</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">act</span><span class="ppsign">></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|16px]]</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|16px]]</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|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:templateId | + | <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;"> Version </th><td xmlns="" style="text-align: left; background-color: #F6F3EE"> gültig ab 2013‑01‑23 Status [[Datei:Kyellow.png|16px]] In Entwicklung</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 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"><</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><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">entryRelationship</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">observation</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">act</span><span class="ppsign">></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"><</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><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">entryRelationship</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">observation</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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><br /></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">act</span><span class="ppsign">></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|16px]]</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|16px]]</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|16px]]</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</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|16px]]</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</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|16px]]</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</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|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</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 19. Juli 2015, 17:05 Uhr
| Template | Pflegediagnose Entry / PflegediagnoseEntry | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Id | 1.2.276.0.76.10.4001 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Version | gültig ab 2013‑01‑23 Status  In Entwicklung | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Klassifikation | CDA Entry Level Template | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Kontext | Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4001 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Offen/Geschlossen | Offen (auch andere als die definierten Elemente sind erlaubt) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Beschreibung | 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). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 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"/> </observation> </entryRelationship></act> | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
