Dokumenttypen: Unterschied zwischen den Versionen
Foemig (Diskussion | Beiträge) (Initialfassung zur Kommentierung) |
Foemig (Diskussion | Beiträge) K |
||
| Zeile 7: | Zeile 7: | ||
!Lvl | !Lvl | ||
!Bezeichnung | !Bezeichnung | ||
| − | ! | + | !Loinc-Code |
| − | ! | + | !Kommentar |
|- | |- | ||
| − | + | !1 | |
| − | + | !Administrative Informationen | |
| | | | ||
| | | | ||
| Zeile 25: | Zeile 25: | ||
|2 | |2 | ||
|Konsens | |Konsens | ||
| − | | | + | | |
| − | |8 | + | |eBPG, eFA-Code: 8 |
|- | |- | ||
| Zeile 32: | Zeile 32: | ||
|eFA-Einwilligung | |eFA-Einwilligung | ||
| | | | ||
| − | |8.1 | + | |eFA-Code: 8.1 |
|- | |- | ||
| Zeile 50: | Zeile 50: | ||
|Sozialbericht | |Sozialbericht | ||
| | | | ||
| − | |5.4 | + | |eFA-Code: 5.4 |
|- | |- | ||
| Zeile 77: | Zeile 77: | ||
|- | |- | ||
| − | + | !1 | |
| − | + | !Strukturierte Dokumente | |
| | | | ||
| | | | ||
| Zeile 91: | Zeile 91: | ||
|3 | |3 | ||
|Diagnose | |Diagnose | ||
| − | | | + | | |
| − | |2 | + | |eBPG, eFA-Code: 2 |
|- | |- | ||
|3 | |3 | ||
|Prozedur | |Prozedur | ||
| − | | | + | | |
| − | |3 | + | |eBPG, eFA-Code: 3 |
|- | |- | ||
| Zeile 104: | Zeile 104: | ||
|Cave | |Cave | ||
| | | | ||
| − | |4.4 | + | |eFA-Code: 4.4 |
|- | |- | ||
| Zeile 110: | Zeile 110: | ||
|Zusammenfassung | |Zusammenfassung | ||
| | | | ||
| − | |4 | + | |eFA-Code: 4 |
|- | |- | ||
|3 | |3 | ||
|Arztbrief | |Arztbrief | ||
| − | | | + | | |
| − | |4.1 | + | |eBPG, eFA-Code: 4.1 |
|- | |- | ||
|4 | |4 | ||
|Entlassbrief | |Entlassbrief | ||
| − | | | + | | |
| − | |4.1.2 | + | |eBPG, eFA-Code: 4.1.2 |
|- | |- | ||
|5 | |5 | ||
|Pflegerischer Entlassbrief | |Pflegerischer Entlassbrief | ||
| − | |||
| | | | ||
| + | |eBPG | ||
|- | |- | ||
| Zeile 134: | Zeile 134: | ||
|Einweisungsbrief | |Einweisungsbrief | ||
| | | | ||
| − | |4.1.1 | + | |eFA-Code: 4.1.1 |
|- | |- | ||
| Zeile 140: | Zeile 140: | ||
|Verlegungsbrief | |Verlegungsbrief | ||
| | | | ||
| − | |4.1.3 | + | |eFA-Code: 4.1.3 |
|- | |- | ||
| Zeile 146: | Zeile 146: | ||
|Bericht / Befund | |Bericht / Befund | ||
| | | | ||
| − | |5 | + | |eFA-Code: 5 |
|- | |- | ||
| Zeile 152: | Zeile 152: | ||
|Strahlentherapiebericht | |Strahlentherapiebericht | ||
| | | | ||
| − | |5.5 | + | |eFA-Code: 5.5 |
|- | |- | ||
| Zeile 158: | Zeile 158: | ||
|Chemotherapiebericht | |Chemotherapiebericht | ||
| | | | ||
| − | |5.6 | + | |eFA-Code: 5.6 |
|- | |- | ||
| Zeile 170: | Zeile 170: | ||
|Konsilbericht | |Konsilbericht | ||
| | | | ||
| − | |5.7 | + | |eFA-Code: 5.7 |
|- | |- | ||
| Zeile 176: | Zeile 176: | ||
|Labordaten | |Labordaten | ||
| | | | ||
| − | |6.2.1 | + | |eFA-Code: 6.2.1 |
|- | |- | ||
| Zeile 182: | Zeile 182: | ||
|CT-Befund | |CT-Befund | ||
| | | | ||
| − | |5.2.1 | + | |eFA-Code: 5.2.1 |
|- | |- | ||
| Zeile 188: | Zeile 188: | ||
|Endoskopie-Befund | |Endoskopie-Befund | ||
| | | | ||
| − | |5.2.2 | + | |eFA-Code: 5.2.2 |
|- | |- | ||
| Zeile 194: | Zeile 194: | ||
|Herzkatheterbefund | |Herzkatheterbefund | ||
| | | | ||
| − | |5.2.3 | + | |eFA-Code: 5.2.3 |
|- | |- | ||
| Zeile 200: | Zeile 200: | ||
|Koloskopiebefund | |Koloskopiebefund | ||
| | | | ||
| − | |5.2.4 | + | |eFA-Code: 5.2.4 |
|- | |- | ||
|4 | |4 | ||
|Laborbefund | |Laborbefund | ||
| − | | | + | | |
| − | |5.2.5 | + | |eBPG, eFA-Code: 5.2.5 |
|- | |- | ||
| Zeile 212: | Zeile 212: | ||
|Mikrobiologiebefund | |Mikrobiologiebefund | ||
| | | | ||
| − | |5.2.7 | + | |eFA-Code: 5.2.7 |
|- | |- | ||
| Zeile 218: | Zeile 218: | ||
|MRT-Befund | |MRT-Befund | ||
| | | | ||
| − | |5.2.6 | + | |eFA-Code: 5.2.6 |
|- | |- | ||
| Zeile 224: | Zeile 224: | ||
|Nachsorgebefund | |Nachsorgebefund | ||
| | | | ||
| − | |5.2.8 | + | |eFA-Code: 5.2.8 |
|- | |- | ||
| Zeile 230: | Zeile 230: | ||
|Neuropathologiebefund | |Neuropathologiebefund | ||
| | | | ||
| − | |5.2.9 | + | |eFA-Code: 5.2.9 |
|- | |- | ||
| Zeile 236: | Zeile 236: | ||
|Pathologiebefund | |Pathologiebefund | ||
| | | | ||
| − | |5.2.10 | + | |eFA-Code: 5.2.10 |
|- | |- | ||
| Zeile 242: | Zeile 242: | ||
|Rektoskopiebefund | |Rektoskopiebefund | ||
| | | | ||
| − | |5.2.11 | + | |eFA-Code: 5.2.11 |
|- | |- | ||
|4 | |4 | ||
|Radiologiebefund | |Radiologiebefund | ||
| − | | | + | | |
| − | |5.2.12 | + | |eBPG, eFA-Code: 5.2.12 |
|- | |- | ||
| Zeile 254: | Zeile 254: | ||
|Sonographiebefund | |Sonographiebefund | ||
| | | | ||
| − | |5.2.13 | + | |eFA-Code: 5.2.13 |
|- | |- | ||
| Zeile 278: | Zeile 278: | ||
|Mutterpass | |Mutterpass | ||
| | | | ||
| − | | | + | |eBPG? |
|- | |- | ||
| Zeile 296: | Zeile 296: | ||
|Anamnesebogen | |Anamnesebogen | ||
| | | | ||
| − | |5.1 | + | |eFA-Code: 5.1 |
|- | |- | ||
| Zeile 302: | Zeile 302: | ||
|QS-Dokument | |QS-Dokument | ||
| | | | ||
| − | |4.3 | + | |eFA-Code: 4.3 |
|- | |- | ||
| Zeile 308: | Zeile 308: | ||
|Anordnungsbogen | |Anordnungsbogen | ||
| | | | ||
| − | |7.2 | + | |eFA-Code: 7.2 |
|- | |- | ||
| Zeile 320: | Zeile 320: | ||
|OP-Bericht | |OP-Bericht | ||
| | | | ||
| − | |5.3 | + | |eFA-Code: 5.3 |
|- | |- | ||
| Zeile 326: | Zeile 326: | ||
|Konferenzprotokoll | |Konferenzprotokoll | ||
| | | | ||
| − | |4.2 | + | |eFA-Code: 4.2 |
|- | |- | ||
| Zeile 332: | Zeile 332: | ||
|Tumorboardprotokoll | |Tumorboardprotokoll | ||
| | | | ||
| − | |4.2.1 | + | |eFA-Code: 4.2.1 |
|- | |- | ||
| Zeile 374: | Zeile 374: | ||
|Therapieplan | |Therapieplan | ||
| | | | ||
| − | |7.1 | + | |eFA-Code: 7.1 |
|- | |- | ||
| Zeile 383: | Zeile 383: | ||
|- | |- | ||
| − | + | !1 | |
| − | + | !Unstrukturierte Dokumente | |
| | | | ||
| | | | ||
| Zeile 398: | Zeile 398: | ||
|2D-Computergrafik | |2D-Computergrafik | ||
| | | | ||
| − | |6.4 | + | |eFA-Code: 6.4 |
|- | |- | ||
| Zeile 404: | Zeile 404: | ||
|EKG | |EKG | ||
| | | | ||
| − | |6.4.1 | + | |eFA-Code: 6.4.1 |
|- | |- | ||
| Zeile 410: | Zeile 410: | ||
|Röntgenbild | |Röntgenbild | ||
| | | | ||
| − | |6.4.2 | + | |eFA-Code: 6.4.2 |
|- | |- | ||
| Zeile 416: | Zeile 416: | ||
|Röntgenserie | |Röntgenserie | ||
| | | | ||
| − | |6.4.3 | + | |eFA-Code: 6.4.3 |
|- | |- | ||
| Zeile 422: | Zeile 422: | ||
|Sonographie | |Sonographie | ||
| | | | ||
| − | |6.4.4 | + | |eFA-Code: 6.4.4 |
| − | |||
|} | |} | ||
| + | |||
| + | Der Kommentar "eBPG" besagt, dass es vorgesehen ist, diesen Dokumenttyp im sog. eBPG-Projekt (MGEPA des Landes NRW) zu behandeln. | ||
Version vom 7. März 2012, 09:04 Uhr
Dokumenttypen
Die möglichen Dokumenttypen bilden eine Hierarchie (Taxonomie), die hier erstmal zur Diskussion gestellt wird. Die letzten beiden Spalten sollten in einer Kommentarzeile zusammengefasst werden. Ausserdem sollte noch mögliche LOINC-Codes direkt hier eingefügt werden, um einen direkten Überblick zu haben:
| Lvl | Bezeichnung | Loinc-Code | Kommentar |
|---|---|---|---|
| 1 | Administrative Informationen | ||
| 2 | Versichertendaten | 1 | |
| 2 | Konsens | eBPG, eFA-Code: 8 | |
| 3 | eFA-Einwilligung | eFA-Code: 8.1 | |
| 3 | BPPC-Dokument | ||
| 3 | Organspendeerklärung | ||
| 2 | Sozialbericht | eFA-Code: 5.4 | |
| 2 | Behandlungsvertrag | ||
| 3 | Selektivvertrag | ||
| 2 | Transaktionen | ||
| 3 | eFA-in-a-Box | ??? | |
| 1 | Strukturierte Dokumente | ||
| 2 | Feingranulare Daten | ||
| 3 | Diagnose | eBPG, eFA-Code: 2 | |
| 3 | Prozedur | eBPG, eFA-Code: 3 | |
| 3 | Cave | eFA-Code: 4.4 | |
| 2 | Zusammenfassung | eFA-Code: 4 | |
| 3 | Arztbrief | eBPG, eFA-Code: 4.1 | |
| 4 | Entlassbrief | eBPG, eFA-Code: 4.1.2 | |
| 5 | Pflegerischer Entlassbrief | eBPG | |
| 4 | Einweisungsbrief | eFA-Code: 4.1.1 | |
| 4 | Verlegungsbrief | eFA-Code: 4.1.3 | |
| 3 | Bericht / Befund | eFA-Code: 5 | |
| 4 | Strahlentherapiebericht | eFA-Code: 5.5 | |
| 4 | Chemotherapiebericht | eFA-Code: 5.6 | |
| 4 | Pflegebericht | ||
| 4 | Konsilbericht | eFA-Code: 5.7 | |
| 4 | Labordaten | eFA-Code: 6.2.1 | |
| 4 | CT-Befund | eFA-Code: 5.2.1 | |
| 4 | Endoskopie-Befund | eFA-Code: 5.2.2 | |
| 4 | Herzkatheterbefund | eFA-Code: 5.2.3 | |
| 4 | Koloskopiebefund | eFA-Code: 5.2.4 | |
| 4 | Laborbefund | eBPG, eFA-Code: 5.2.5 | |
| 5 | Mikrobiologiebefund | eFA-Code: 5.2.7 | |
| 4 | MRT-Befund | eFA-Code: 5.2.6 | |
| 4 | Nachsorgebefund | eFA-Code: 5.2.8 | |
| 4 | Neuropathologiebefund | eFA-Code: 5.2.9 | |
| 4 | Pathologiebefund | eFA-Code: 5.2.10 | |
| 4 | Rektoskopiebefund | eFA-Code: 5.2.11 | |
| 4 | Radiologiebefund | eBPG, eFA-Code: 5.2.12 | |
| 4 | Sonographiebefund | eFA-Code: 5.2.13 | |
| 3 | Pass | ||
| 4 | Impf-Pass | ||
| 4 | Röntgen-Pass | ||
| 4 | Mutterpass | eBPG? | |
| 4 | Kinderuntersuchungsheft | ||
| 2 | Formular | ||
| 3 | Anamnesebogen | eFA-Code: 5.1 | |
| 3 | QS-Dokument | eFA-Code: 4.3 | |
| 3 | Anordnungsbogen | eFA-Code: 7.2 | |
| 2 | Protokoll | ||
| 3 | OP-Bericht | eFA-Code: 5.3 | |
| 3 | Konferenzprotokoll | eFA-Code: 4.2 | |
| 3 | Tumorboardprotokoll | eFA-Code: 4.2.1 | |
| 2 | Meldungen | ||
| 3 | Infektionsschutz | ||
| 3 | Tumorregister | ||
| 4 | Klinische Tumorregister | ||
| 4 | Epidemiologische Tumorregister | ||
| 2 | Planung | ||
| 3 | Therapieplan | eFA-Code: 7.1 | |
| 3 | Trainingsplan | ||
| 1 | Unstrukturierte Dokumente | ||
| 2 | Bild | ||
| 3 | 2D-Computergrafik | eFA-Code: 6.4 | |
| 3 | EKG | eFA-Code: 6.4.1 | |
| 3 | Röntgenbild | eFA-Code: 6.4.2 | |
| 3 | Röntgenserie | eFA-Code: 6.4.3 | |
| 3 | Sonographie | eFA-Code: 6.4.4 |
Der Kommentar "eBPG" besagt, dass es vorgesehen ist, diesen Dokumenttyp im sog. eBPG-Projekt (MGEPA des Landes NRW) zu behandeln.
