Patienteneinwilligung: Unterschied zwischen den Versionen
Foemig (Diskussion | Beiträge) (Die Seite wurde neu angelegt: „==Patienteneinwilligung== Es liegt die Anforderung vor, die Informationen zu einer Patienteneinwilligung zu kommunizieren. Dies kann auf verschiedene Art und Weis…“) |
Foemig (Diskussion | Beiträge) (→CON-Segment) |
||
Zeile 6: | Zeile 6: | ||
* ... | * ... | ||
− | ===CON-Segment=== | + | ===CON-Segment (Einverständniserklärung)=== |
− | + | This segment identifies patient consent information relating to a particular message. It can be used as part of existing messages to convey information about patient consent to procedures, admissions, information release/exchange or other events discussed by the message. It may also be used in messages focusing on recording or requesting consent and for consents related to employees or service providers. | |
+ | |||
+ | The segment will be used in conjunction with various other segments to identify the practitioner (PRA/STF) or patient (PID) the consent is for, the various individuals involved in the consent (ROL) as witnesses, consenting person (not always the patient), translators, consulting providers, etc., and the specific procedures being proposed (PR1). | ||
+ | |||
+ | |||
+ | The consent segment provides details about a specific consent by a patient or staff member. | ||
+ | |||
+ | {| class="hl7table" | ||
+ | !Seq | ||
+ | !Description | ||
+ | !German Interpretation | ||
+ | !Length | ||
+ | !Table | ||
+ | !r/o/c | ||
+ | !Rep# | ||
+ | !Item | ||
+ | !Data Structure | ||
+ | !Section | ||
− | |||
|- | |- | ||
− | + | |1 | |
+ | |Set ID - CON | ||
+ | |CON-Segmentnummer | ||
+ | |4 | ||
+ | | | ||
+ | |R | ||
+ | | | ||
+ | |01776 | ||
+ | |SI | ||
+ | |9.9.4.1 | ||
+ | |||
|- | |- | ||
− | || | + | |2 |
− | + | |Consent Type | |
− | + | |Art der Einverständniserklärung | |
+ | |705 | ||
+ | |0496 | ||
+ | !RE (O) | ||
+ | | | ||
+ | |01777 | ||
+ | |CWE | ||
+ | |9.9.4.2 | ||
+ | |||
|- | |- | ||
− | | | + | |3 |
− | + | |Consent Form ID and Version | |
+ | |verwendetes Formular der Einverständniserklärung | ||
+ | |40 | ||
+ | | | ||
+ | |O | ||
+ | | | ||
+ | |01778 | ||
+ | |ST | ||
+ | |9.9.4.3 | ||
+ | |||
|- | |- | ||
− | | | + | |4 |
− | + | |Consent Form Number | |
− | | | + | |eindeutige Identifikation der Einverständniserklärung |
+ | |427 | ||
+ | | | ||
+ | |O | ||
+ | | | ||
+ | |01779 | ||
+ | |EI | ||
+ | |9.9.4.4 | ||
+ | |||
|- | |- | ||
− | | | + | |5 |
− | + | |Consent Text | |
− | + | |Einverständnis - Text | |
+ | |65536 | ||
+ | | | ||
+ | |O | ||
+ | |Y | ||
+ | |01780 | ||
+ | |FT | ||
+ | |9.9.4.5 | ||
+ | |||
|- | |- | ||
− | | | + | |6 |
− | + | |Subject-specific Consent Text | |
+ | |Spezifische Einverständnisse | ||
+ | |65536 | ||
+ | | | ||
+ | |O | ||
+ | |Y | ||
+ | |01781 | ||
+ | |FT | ||
+ | |9.9.4.6 | ||
+ | |||
|- | |- | ||
− | | | + | |7 |
− | + | |Consent Background Information | |
+ | |zusätzliche Informationen | ||
+ | |65536 | ||
+ | | | ||
+ | |O | ||
+ | |Y | ||
+ | |01782 | ||
+ | |FT | ||
+ | |9.9.4.7 | ||
+ | |||
|- | |- | ||
− | | | + | |8 |
− | + | |Subject-specific Consent Background Text | |
+ | |spezifische Zusatzinformationen | ||
+ | |65536 | ||
+ | | | ||
+ | |O | ||
+ | |Y | ||
+ | |01783 | ||
+ | |FT | ||
+ | |9.9.4.8 | ||
+ | |||
|- | |- | ||
− | | | + | |9 |
− | + | |Consenter-imposed limitations | |
+ | |Einschränkungen durch den Einwilligenden | ||
+ | |65536 | ||
+ | | | ||
+ | |O | ||
+ | |Y | ||
+ | |01784 | ||
+ | |FT | ||
+ | |9.9.4.9 | ||
+ | |||
|- | |- | ||
− | | | + | |10 |
− | + | |Consent Mode | |
+ | |Form der Einverständniserklärung | ||
+ | |2 | ||
+ | |0497 | ||
+ | !R (O) | ||
+ | | | ||
+ | |01785 | ||
+ | |CNE | ||
+ | |9.9.4.10 | ||
+ | |||
|- | |- | ||
− | | | + | |11 |
− | + | |Consent Status | |
+ | |Status der Einverständniserklärung | ||
+ | |2 | ||
+ | |0498 | ||
+ | |R | ||
+ | | | ||
+ | |01786 | ||
+ | |CNE | ||
+ | |9.9.4.11 | ||
+ | |||
|- | |- | ||
− | | | + | |12 |
− | + | |Consent Discussion Date/Time | |
+ | |Zeitpunkt des Patientengesprächs | ||
+ | |24 | ||
+ | | | ||
+ | |O | ||
+ | | | ||
+ | |01787 | ||
+ | |DTM | ||
+ | |9.9.4.12 | ||
+ | |||
|- | |- | ||
− | | | + | |13 |
− | + | |Consent Decision Date/Time | |
− | + | |Zeitpunkt der Patientenentscheidung | |
+ | |24 | ||
+ | | | ||
+ | |O | ||
+ | | | ||
+ | |01788 | ||
+ | |DTM | ||
+ | |9.9.4.13 | ||
+ | |||
|- | |- | ||
− | | | + | |14 |
− | + | |Consent Effective Date/Time | |
− | + | |Beginn des Einverständniszeitraums | |
+ | |24 | ||
+ | | | ||
+ | !R (O) | ||
+ | | | ||
+ | |01789 | ||
+ | |DTM | ||
+ | |9.9.4.14 | ||
+ | |||
|- | |- | ||
− | | | + | |15 |
− | + | |Consent End Date/Time | |
− | + | |Ende des Einverständniszeitraums | |
+ | |24 | ||
+ | | | ||
+ | !RE (O) | ||
+ | | | ||
+ | |01790 | ||
+ | |DTM | ||
+ | |9.9.4.15 | ||
+ | |||
|- | |- | ||
− | | | + | |16 |
− | + | |Subject Competence Indicator | |
− | + | |Merkmal Patientenverständnis vorhanden | |
+ | |1 | ||
+ | |0136 | ||
+ | |O | ||
+ | | | ||
+ | |01791 | ||
+ | |ID | ||
+ | |9.9.4.16 | ||
+ | |||
|- | |- | ||
− | | | + | |17 |
− | | | + | |Translator Assistance Indicator |
+ | |Merkmal Dolmetscher benötigt | ||
+ | |1 | ||
+ | |0136 | ||
+ | |O | ||
+ | | | ||
+ | |01792 | ||
+ | |ID | ||
+ | |9.9.4.17 | ||
+ | |||
|- | |- | ||
− | | | + | |18 |
− | + | |Language Translated To | |
+ | |übersetzt nach | ||
+ | |250 | ||
+ | |0296 | ||
+ | |O | ||
+ | | | ||
+ | |01793 | ||
+ | |CWE | ||
+ | |9.9.4.18 | ||
+ | |||
|- | |- | ||
− | | | + | |19 |
− | + | |Informational Material Supplied Indicator | |
+ | |Merkmal zusätzliches Informationsmaterial ausgehändigt | ||
+ | |1 | ||
+ | |0136 | ||
+ | |O | ||
+ | | | ||
+ | |01794 | ||
+ | |ID | ||
+ | |9.9.4.19 | ||
+ | |||
|- | |- | ||
− | | | + | |20 |
− | + | |Consent Bypass Reason | |
+ | |Grund für Nichteinholung eines Einverständnisses | ||
+ | |705 | ||
+ | |0499 | ||
+ | |O | ||
+ | | | ||
+ | |01795 | ||
+ | |CWE | ||
+ | |9.9.4.20 | ||
+ | |||
|- | |- | ||
− | | | + | |21 |
− | + | |Consent Disclosure Level | |
+ | |Umfang der Patientenaufklärung | ||
+ | |1 | ||
+ | |0500 | ||
+ | |O | ||
+ | | | ||
+ | |01796 | ||
+ | |ID | ||
+ | |9.9.4.21 | ||
+ | |||
|- | |- | ||
− | | | + | |22 |
− | + | |Consent Non-disclosure Reason | |
+ | |Grund für eingeschränkte Patientenaufklärung | ||
+ | |705 | ||
+ | |0501 | ||
+ | |O | ||
+ | | | ||
+ | |01797 | ||
+ | |CWE | ||
+ | |9.9.4.22 | ||
+ | |||
|- | |- | ||
− | | | + | |23 |
− | + | |Non-subject Consenter Reason | |
+ | |Grund für die Einwilligung durch Dritte | ||
+ | |705 | ||
+ | |0502 | ||
+ | |O | ||
+ | | | ||
+ | |01798 | ||
+ | |CWE | ||
+ | |9.9.4.23 | ||
+ | |||
|- | |- | ||
− | | | + | |24 |
− | + | |Consenter ID | |
− | + | |Einwilligende Person | |
− | + | |250 | |
− | + | | | |
+ | |R | ||
+ | |Y | ||
+ | |01909 | ||
+ | |XPN | ||
+ | |9.9.4.24 | ||
+ | |||
|- | |- | ||
− | |25 | + | |25 |
+ | |Relationship to Subject | ||
+ | |Beziehung des Einwilligenden zum Patienten | ||
+ | |100 | ||
+ | |0548 | ||
+ | |R | ||
+ | |Y | ||
+ | |01898 | ||
+ | |IS | ||
+ | |9.9.4.25 | ||
|} | |} | ||
+ | |||
+ | ==Nachrichtenstruktur== | ||
+ | |||
+ | MSH | ||
+ | ... | ||
+ | PID | ||
+ | [PV1] | ||
+ | ... | ||
+ | [{ CON }] | ||
+ | |||
+ | |||
+ | ==Nutzung== | ||
+ | Das CON-Segment ist optional und wiederholbar in den Nachrichten einzusetzen. |
Version vom 21. Oktober 2011, 15:41 Uhr
Inhaltsverzeichnis
Patienteneinwilligung
Es liegt die Anforderung vor, die Informationen zu einer Patienteneinwilligung zu kommunizieren. Dies kann auf verschiedene Art und Weise geschehen:
- CON-Segment
- BPPR Integration Profile
- ...
CON-Segment (Einverständniserklärung)
This segment identifies patient consent information relating to a particular message. It can be used as part of existing messages to convey information about patient consent to procedures, admissions, information release/exchange or other events discussed by the message. It may also be used in messages focusing on recording or requesting consent and for consents related to employees or service providers.
The segment will be used in conjunction with various other segments to identify the practitioner (PRA/STF) or patient (PID) the consent is for, the various individuals involved in the consent (ROL) as witnesses, consenting person (not always the patient), translators, consulting providers, etc., and the specific procedures being proposed (PR1).
The consent segment provides details about a specific consent by a patient or staff member.
Seq | Description | German Interpretation | Length | Table | r/o/c | Rep# | Item | Data Structure | Section |
---|---|---|---|---|---|---|---|---|---|
1 | Set ID - CON | CON-Segmentnummer | 4 | R | 01776 | SI | 9.9.4.1 | ||
2 | Consent Type | Art der Einverständniserklärung | 705 | 0496 | RE (O) | 01777 | CWE | 9.9.4.2 | |
3 | Consent Form ID and Version | verwendetes Formular der Einverständniserklärung | 40 | O | 01778 | ST | 9.9.4.3 | ||
4 | Consent Form Number | eindeutige Identifikation der Einverständniserklärung | 427 | O | 01779 | EI | 9.9.4.4 | ||
5 | Consent Text | Einverständnis - Text | 65536 | O | Y | 01780 | FT | 9.9.4.5 | |
6 | Subject-specific Consent Text | Spezifische Einverständnisse | 65536 | O | Y | 01781 | FT | 9.9.4.6 | |
7 | Consent Background Information | zusätzliche Informationen | 65536 | O | Y | 01782 | FT | 9.9.4.7 | |
8 | Subject-specific Consent Background Text | spezifische Zusatzinformationen | 65536 | O | Y | 01783 | FT | 9.9.4.8 | |
9 | Consenter-imposed limitations | Einschränkungen durch den Einwilligenden | 65536 | O | Y | 01784 | FT | 9.9.4.9 | |
10 | Consent Mode | Form der Einverständniserklärung | 2 | 0497 | R (O) | 01785 | CNE | 9.9.4.10 | |
11 | Consent Status | Status der Einverständniserklärung | 2 | 0498 | R | 01786 | CNE | 9.9.4.11 | |
12 | Consent Discussion Date/Time | Zeitpunkt des Patientengesprächs | 24 | O | 01787 | DTM | 9.9.4.12 | ||
13 | Consent Decision Date/Time | Zeitpunkt der Patientenentscheidung | 24 | O | 01788 | DTM | 9.9.4.13 | ||
14 | Consent Effective Date/Time | Beginn des Einverständniszeitraums | 24 | R (O) | 01789 | DTM | 9.9.4.14 | ||
15 | Consent End Date/Time | Ende des Einverständniszeitraums | 24 | RE (O) | 01790 | DTM | 9.9.4.15 | ||
16 | Subject Competence Indicator | Merkmal Patientenverständnis vorhanden | 1 | 0136 | O | 01791 | ID | 9.9.4.16 | |
17 | Translator Assistance Indicator | Merkmal Dolmetscher benötigt | 1 | 0136 | O | 01792 | ID | 9.9.4.17 | |
18 | Language Translated To | übersetzt nach | 250 | 0296 | O | 01793 | CWE | 9.9.4.18 | |
19 | Informational Material Supplied Indicator | Merkmal zusätzliches Informationsmaterial ausgehändigt | 1 | 0136 | O | 01794 | ID | 9.9.4.19 | |
20 | Consent Bypass Reason | Grund für Nichteinholung eines Einverständnisses | 705 | 0499 | O | 01795 | CWE | 9.9.4.20 | |
21 | Consent Disclosure Level | Umfang der Patientenaufklärung | 1 | 0500 | O | 01796 | ID | 9.9.4.21 | |
22 | Consent Non-disclosure Reason | Grund für eingeschränkte Patientenaufklärung | 705 | 0501 | O | 01797 | CWE | 9.9.4.22 | |
23 | Non-subject Consenter Reason | Grund für die Einwilligung durch Dritte | 705 | 0502 | O | 01798 | CWE | 9.9.4.23 | |
24 | Consenter ID | Einwilligende Person | 250 | R | Y | 01909 | XPN | 9.9.4.24 | |
25 | Relationship to Subject | Beziehung des Einwilligenden zum Patienten | 100 | 0548 | R | Y | 01898 | IS | 9.9.4.25 |
Nachrichtenstruktur
MSH ... PID [PV1] ... [{ CON }]
Nutzung
Das CON-Segment ist optional und wiederholbar in den Nachrichten einzusetzen.