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Version vom 1. Dezember 2017, 13:23 Uhr
Nachfolgend ein Beispieldokument:
1<?xml version="1.0" encoding="UTF-8"?>
2<?xml-stylesheet type="text/xsl" href="eau.xslt"?>
3<?xml-model href="../../abde-runtime-develop/abde-abplus.sch" type="application/xml" schematypens="http://purl.oclc.org/dsdl/schematron"?>
4<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:pharm="urn:ihe:pharm:medication" xsi:schemaLocation="urn:hl7-org:v3 ../schemas/CDA.xsd">
5 <realmCode code="DE"/>
6 <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
7 <templateId root="1.2.276.0.76.10.1020"/>
8 <id root="1.2.276.0.76.3645.239" extension="di-b02e97c1-3cea-4ed4-80cd-5d8a7386cee2" />
9 <code code="xERST_END" codeSystem="2.16.840.1.113883.6.1" displayName="Arbeitsunfähigkeitserst-/-endbescheinigung"/>
10 <title>eAU vom 25. Oktober 2017</title>
11 <effectiveTime value="20171025123415"/>
12 <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
13 <languageCode code="de-DE"/>
14 <setId root="1.2.276.0.76.3645.239" extension="si-b8a7b265-4e20-4177-8cfb-149491b8003a"/>
15 <versionNumber value="1"/>
16 <recordTarget>
17 <patientRole>
18 <id extension="1543627549" root="1.2.276.0.76.4.1"/>
19 <addr>
20 <streetAddressLine>Riedemannweg 59</streetAddressLine>
21 <postalCode>13627</postalCode>
22 <city>Berlin</city>
23 </addr>
24 <telecom use="HP" value="tel:030.456.345345"/>
25 <patient>
26 <name>
27 <given>Paul</given>
28 <family>Pappel</family>
29 </name>
30 <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
31 <birthTime value="19551217"/>
32 <birthplace>
33 <place>
34 <addr>
35 <city>Sassnitz</city>
36 </addr>
37 </place>
38 </birthplace>
39 </patient>
40 </patientRole>
41 </recordTarget>
42 <author>
43 <!--- author -->
44 <time value="20151104"/>
45 <assignedAuthor>
46 <id extension="ied8984938" root="2.16.840.1.113883.3.67.933"/>
47 <assignedPerson>
48 <name>
49 <prefix qualifier="AC">Dr. med.</prefix>
50 <given>Theo</given>
51 <family>Phyllin</family>
52 </name>
53 </assignedPerson>
54 <representedOrganization>
55 <id extension="1443984938" root="BSNR"/>
56 <name>Praxis Dr. med. Phyllin</name>
57 <telecom use="WP" value="tel:0214.2127070"/>
58 <telecom use="WP" value="tel:0214.212707122"/>
59 <addr>
60 <streetName>Krankenhausstraße</streetName>
61 <houseNumber>240</houseNumber>
62 <postalCode>51371</postalCode>
63 <city>Leverkusen</city>
64 </addr>
65 </representedOrganization>
66 </assignedAuthor>
67 </author>
68 <custodian>
69 <assignedCustodian>
70 <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
71 <id extension="M345" root="1.2.276.0.58"/>
72 <name>Praxis Dr. med. Phyllin</name>
73 <telecom use="WP" value="tel:0214.2127070"/>
74 <addr>
75 <streetName>Krankenhausstraße</streetName>
76 <houseNumber>240</houseNumber>
77 <postalCode>51371</postalCode>
78 <city>Leverkusen</city>
79 </addr>
80 </representedCustodianOrganization>
81 </assignedCustodian>
82 </custodian>
83 <legalAuthenticator typeCode="LA" contextControlCode="OP">
84 <time value="20171004"/>
85 <signatureCode code="S"/>
86 <assignedEntity>
87 <!-- nur als ID (identisch zu author) -->
88 <id extension="ied8984938" root="2.16.840.1.113883.3.67.933"/>
89 </assignedEntity>
90 </legalAuthenticator>
91 <component>
92 <structuredBody>
93 <!-- Versicherung Section -->
94 <component typeCode="COMP" >
95 <section>
96 <templateId root="xxxxxx"/>
97 <code code="48768-0" codeSystem="2.16.840.1.113883.6.1"/>
98 <title>Versicherung</title>
99 <!-- Versicherung/Coverage -->
100 <entry>
101 <act classCode="ACT" moodCode="EVN">
102 <templateId/>
103 <id/>
104 <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" />
105 <statusCode code="completed"/>
106 <entryRelationship typeCode="COMP">
107 <!-- Versicherungspolicy -->
108 <act classCode="ACT" moodCode="EVN">
109 <templateId root="VERSICHERUNG" />
110 <code code="VERSICHERUNG" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
111 <statusCode code="completed"/>
112 <!-- Payer Information -->
113 <performer>
114 <assignedEntity>
115 <id extension="Kassen-ID-47" />
116 <addr>
117 <streetAddressLine>AOK-Weg 1459</streetAddressLine>
118 <postalCode>10111</postalCode>
119 <city>Berlin</city>
120 </addr>
121 <representedOrganization>
122 <name>Versicherung AOK Berlin</name>
123 </representedOrganization>
124 </assignedEntity>
125 </performer>
126 <!-- Guarantor -->
127 <!--
128 <performer modeCode="WRITTEN" />
129 -->
130 <!-- Versicherung -->
131 <participant typeCode="COV">
132 <time>
133 <high value="20181231"/>
134 </time>
135 <participantRole>
136 <!-- Versichertenstatus -->
137 <code code="1"/>
138 </participantRole>
139 </participant>
140 <!-- Versicherter -->
141 <participant typeCode="HLD">
142 <participantRole>
143 <id root="xxxxxxxxx" extension="VNR=4711" />
144 </participantRole>
145 </participant>
146 <entryRelationship typeCode="COMP" >
147 <!-- Person Group Observation -->
148 <observation classCode="OBS" moodCode="EVN" >
149 <templateId root="PRSNGRP" />
150 <code code="PRSNGRP" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
151 <!-- aus S_KBV_PERSONENGRUPPE -->
152 <value xsi:type="CD" code="4" codeSystem="1.2.276.0.76.11.151" displayName="SOZ"/>
153 </observation>
154 </entryRelationship>
155 <entryRelationship typeCode="COMP" >
156 <!-- DMP Observation -->
157 <observation classCode="OBS" moodCode="EVN">
158 <templateId root="DMP" />
159 <code code="DMP" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
160 <!-- aus S_KBV_DMP -->
161 <value xsi:type="CD" code="D" codeSystem="1.2.276.0.76.11.138"/>
162 </observation>
163 </entryRelationship>
164 <entryRelationship typeCode="COMP" >
165 <!-- DMP Observation -->
166 <observation classCode="OBS" moodCode="EVN">
167 <templateId root="ASV" />
168 <code code="ASV" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
169 <!-- aus S_KBV_ASV -->
170 <value xsi:type="CD" code="A" />
171 </observation>
172 </entryRelationship>
173 </act>
174 </entryRelationship>
175 </act>
176 </entry>
177 </section>
178 </component>
179 <!-- AU-Diagnose Section -->
180 <component>
181 <section>
182 <templateId root="xxxxxx"/>
183 <code code="AU-DIAGNOSIS" />
184 <title>AU-begründende Diagnosen</title>
185 <text>Der Patient will einfach nicht arbeiten!</text>
186 <entry>
187 <observation classCode="OBS" moodCode="EVN">
188 <code code="x47"/>
189 <statusCode code="completed"/>
190 </observation>
191 </entry>
192 <entry>
193 <observation classCode="OBS" moodCode="EVN">
194 <code code="x80"/>
195 <statusCode code="completed"/>
196 </observation>
197 </entry>
198 </section>
199 </component>
200 <!-- Findings Section -->
201 <component>
202 <section>
203 <templateId/>
204 <text>
205
206 </text>
207 </section>
208 </component>
209 <!-- Accident/Unfall Section -->
210 <component>
211 <section>
212 <templateId/>
213 <code code="ACCIDENT"/>
214 <title>Unfall</title>
215 <entry>
216 <observation classCode="OBS" moodCode="EVN">
217 <templateId/>
218 <code code="ACCIDENT"/>
219 <statusCode code="completed"/>
220 <effectiveTime/>
221 <!-- aus S_KBV_01_Accident -->
222 <value xsi:type="CD" code="D-ARZT" codeSystem="1.2.276.0.76.3.1.135.8.11.4"/>
223 </observation>
224 </entry>
225 </section>
226 </component>
227 <!-- Treatment Section -->
228 <component>
229 <section>
230 <templateId/>
231 <code code="TREATMENT"/>
232 <title>Einleitung besonderer Maßnahmen</title>
233 <text>
234 keine Ahnung, was sonst noch zu tun ist
235 </text>
236 <!-- Treatment stufenweise Wiedereingliederung -->
237 <entry>
238 <observation classCode="OBS" moodCode="EVN">
239 <code code="EINGLIEDERUNG" />
240 <value xsi:type="BL" value="false"/>
241 </observation>
242 </entry>
243 <!-- Treatment Leistungen med. Reha Observation -->
244 <entry>
245 <observation classCode="OBS" moodCode="EVN">
246 <code code="REHA" />
247 <value xsi:type="BL" value="true"/>
248 </observation>
249 </entry>
250 </section>
251 </component>
252 <!-- Temporary Disablement Section -->
253 <component>
254 <section>
255 <templateId/>
256 <code code="TEMPDISABLE"/>
257 <title>Arbeitsunfähigkeit</title>
258 <entry>
259 <observation classCode="OBS" moodCode="EVN">
260 <code code="X-IATWRK" codeSystem="2.16.840.1.113883.6.1"/>
261 <text>
262 beliebiger Text
263 </text>
264 <statusCode code="completed"/>
265 <effectiveTime>
266 <!-- Zeitraum der Arbeitsunfähigkeit -->
267 <low value="20171018"/>
268 <high value="20171020"/>
269 </effectiveTime>
270 <value xsi:type="PQ" unit="%" value="100" />
271 <performer>
272 <!-- festgestellt am -->
273 <time value="20171019"/>
274 <assignedEntity>
275 <id/>
276 <assignedPerson>
277 <name>Hugo Müller</name>
278 </assignedPerson>
279 </assignedEntity>
280 </performer>
281 </observation>
282 </entry>
283 </section>
284 </component>
285 </structuredBody>
286 </component>
287</ClinicalDocument>
