1.2.276.0.76.10.4080/static-2015-12-06T000000

Template	Diagnose Observation / DiagnoseObservation
Id	1.2.276.0.76.10.4080
Version	gültig ab 2015‑12‑06 Status In Entwicklung
Klassifikation	CDA Entry Level Template
Kontext	Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4080
Offen/Geschlossen	Offen (auch andere als die definierten Elemente sind erlaubt)
Beschreibung	This template reflects a discrete observation about a patient's problem. Because it is a discrete observation, it will have a statusCode of "completed". The effectiveTime, also referred to as the “biologically relevant time” is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of heart attack that occurred five years ago, the effectiveTime is five years ago. The effectiveTime of the Problem Observation is the definitive indication of whether or not the underlying condition is resolved. If the problem is known to be resolved, then an effectiveTime/high would be present. If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK".
Benutzt von / Benutzt	Benutzt von / Benutzt 5 Templates Benutzt von Template-Id als Name Version 1.2.276.0.76.10.4079 Containment DiagnoseConcernAct Diagnose Concern Act 2015‑12‑06 Benutzt Template-Id als Name Version 1.2.276.0.76.10.90025 Inklusion CDAAuthorBody DYNAMIC 1.2.276.0.76.10.4077 Containment AgeObservation DYNAMIC 1.2.276.0.76.10.4078 Containment PrognosisObservation DYNAMIC 1.2.276.0.76.10.4076 Containment PriorityPreference DYNAMIC
Beziehung	Spezialisierung: Template 2.16.840.1.113883.10.12.303 (2005‑09‑07) Adaptation: Template 2.16.840.1.113883.10.20.22.4.4 (2015‑08‑01) Spezialisierung: Template 1.2.276.0.76.10.4075 (2015‑12‑06)
Beispiel	<observation classCode="OBS" moodCode="EVN">   <!-- Diagnose Observation -->   <templateId root="1.2.276.0.76.10.4080"/>   <id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>   <code code="75324-" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis"/>   <!-- The statusCode reflects the status of the observation itself -->   <statusCode code="completed"/>   <effectiveTime>     <!-- Das low Element gibt das Datum an, seit wann der Patient diese Diagnose hat -->     <low value="20130703"/>     <!-- Das high Element gibt das Datum an, seit wann der Patient diese Diagnose nicht mehr hat -->     <high value="20080814"/>   </effectiveTime>  <!-- Im value Element wird die kodierte Diagnose angegeben, z. B. als ICD-10 GM 2016 (OID 1.2.276.0.76.5.430): J11.1 Grippe mit sonstigen Manifestationen an den Atemwegen, Viren nicht nachgewiesen -->   <value xsi:type="CD" code="J11.1" codeSystem="1.2.276.0.76.5.430" displayName="Grippe mit sonstigen Manifestationen an den Atemwegen, Viren nicht nachgewiesen"/>   <author typeCode="AUT">     <!-- optional: Autor der Diagnose -->   </author></observation>
Item DT Kard Konf Beschreibung Label hl7:observation (DiagnoseObservation) @classCode cs 1 .. 1 F OBS @moodCode cs 1 .. 1 F EVN @negationInd bl 0 .. 1   hl7:templateId 1 .. 1 M (DiagnoseObservation) @root uid 1 .. 1 F 1.2.276.0.76.10.4080 hl7:id 1 .. * (DiagnoseObservation) hl7:code 1 .. 1 M (DiagnoseObservation) @code 1 .. 1 F 75324-4 @codeSystem 1 .. 1 F 2.16.840.1.113883.6.1 (LOINC) hl7:statusCode 1 .. 1 M (DiagnoseObservation) @code 1 .. 1 F completed hl7:effectiveTime 1 .. 1 M If the problem is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'. Therefore, the existence of an high element within a problem does indicate that the problem has been resolved. (DiagnoseObservation) hl7:low 1 .. 1 M Das low Element gibt das Datum an, seit wann der Patient diese Diagnose hat (DiagnoseObservation) hl7:high 0 .. 1 Das high Element gibt das Datum an, seit wann der Patient diese Diagnose nicht mehr hat (DiagnoseObservation) hl7:value CD 1 .. 1 R (DiagnoseObservation)   CONF muss aus der Konzeptdomäne "Diagnosecodes" gewählt werden hl7:qualifier 0 .. * This value MAY contain zero or more [0..*] qualifier (CONF:1198-31870). The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML. (DiagnoseObservation) hl7:translation 0 .. * CONF:1198‑16749 @code 0 .. 1     MAY contain zero or one [0..1] @code (CodeSystem: ICD10CM urn:oid:2.16.840.1.113883.6.90 STATIC) (CONF:1198-16750). hl7:author 0 .. * R (DiagnoseObservation) Eingefügt von 1.2.276.0.76.10.90025 CDA Author (Body) (DYNAMIC) @typeCode 0 .. 1 F AUT @context​Control​Code 0 .. 1 F OP hl7:functionCode CE 0 .. 1 (DiagnoseObservation)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC) hl7:time TS 1 .. 1 R (DiagnoseObservation) hl7:assignedAuthor 1 .. 1 R (DiagnoseObservation) @classCode 0 .. 1 F ASSIGNED hl7:id II 1 .. * R (DiagnoseObservation) hl7:code CE 0 .. 1 (DiagnoseObservation) @codeSystem 1 .. 1 F 2.16.840.1.113883.5.111 (Role Code) hl7:addr AD 0 .. * (DiagnoseObservation) hl7:telecom TEL 0 .. * (DiagnoseObservation) hl7:assigned​Person 0 .. 1 (DiagnoseObservation) Eingefügt von 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC) @classCode 0 .. 1 F PSN @determiner​Code 0 .. 1 F INSTANCE hl7:name PN 1 .. 1 (DiagnoseObservation) hl7:represented​Organization 0 .. 1 (DiagnoseObservation) Eingefügt von 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC) @classCode 0 .. 1 F ORG @determiner​Code 0 .. 1 F INSTANCE hl7:id II 0 .. * (DiagnoseObservation) hl7:name ON 1 .. 1 (DiagnoseObservation) hl7:telecom TEL 0 .. * (DiagnoseObservation) hl7:addr AD 0 .. 1 (DiagnoseObservation) hl7:entryRelationship 0 .. 1 (DiagnoseObservation) @typeCode cs 1 .. 1 F SUBJ @inversionInd bl 1 .. 1 F true   Beinhaltet 1.2.276.0.76.10.4077 Alter Observation (DYNAMIC) hl7:entryRelationship 0 .. 1 (DiagnoseObservation) @typeCode cs 1 .. 1 F REFR   Beinhaltet 1.2.276.0.76.10.4078 Prognose Observation (DYNAMIC) hl7:entryRelationship 0 .. * Wichtigkeit der Diagnose laut Einschätzung des Gesundheitsdienstleisters (DiagnoseObservation) @typeCode cs 1 .. 1 F REFR   Beinhaltet 1.2.276.0.76.10.4076 Priorität Preference (DYNAMIC)