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Zeile 1: |
| − | Nachfolgend ein Beispieldokument:
| + | XML-Materialien: Schemas, Schematron und XML-Beispieldokumente sowie zugehörige Stylesheets finden sich auf den Publikationsseiten von HL7 Deutschland unter http://hl7de.art-decor.org oder direkt unter der [http://hl7de.art-decor.org/index.php?prefix=vomgt- Materialienseite des Projekts]. |
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| − | <syntaxhighlight lang="xml" valid="true" line="1" highlight="2-3">
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| − | <?xml version="1.0" encoding="UTF-8"?>
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| − | <?xml-stylesheet type="text/xsl" href="eau.xslt"?>
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| − | <?xml-model href="../../abde-runtime-develop/abde-abplus.sch" type="application/xml" schematypens="http://purl.oclc.org/dsdl/schematron"?>
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| − | <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">
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| − | <realmCode code="DE"/>
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| − | <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
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| − | <templateId root="1.2.276.0.76.10.1020"/>
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| − | <id root="1.2.276.0.76.3645.239" extension="di-b02e97c1-3cea-4ed4-80cd-5d8a7386cee2" />
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| − | <code code="85216-0" codeSystem="2.16.840.1.113883.6.1" displayName="Disability examination note"/>
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| − | <title>eAU vom 25. Oktober 2017</title>
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| − | <effectiveTime value="20171025123415"/>
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| − | <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
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| − | <languageCode code="de-DE"/>
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| − | <setId root="1.2.276.0.76.3645.239" extension="si-b8a7b265-4e20-4177-8cfb-149491b8003a"/>
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| − | <versionNumber value="1"/>
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| − | <recordTarget>
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| − | <patientRole>
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| − | <id extension="1543627549" root="1.2.276.0.76.4.1"/>
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| − | <addr>
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| − | <streetAddressLine>Riedemannweg 59</streetAddressLine>
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| − | <postalCode>13627</postalCode>
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| − | <city>Berlin</city>
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| − | </addr>
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| − | <telecom use="HP" value="tel:030.456.345345"/>
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| − | <patient>
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| − | <name>
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| − | <given>Paul</given>
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| − | <family>Pappel</family>
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| − | </name>
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| − | <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
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| − | <birthTime value="19551217"/>
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| − | <birthplace>
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| − | <place>
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| − | <addr>
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| − | <city>Sassnitz</city>
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| − | </addr>
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| − | </place>
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| − | </birthplace>
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| − | </patient>
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| − | </patientRole>
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| − | </recordTarget>
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| − | <author>
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| − | <!--- author -->
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| − | <time value="20151104"/>
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| − | <assignedAuthor>
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| − | <id extension="ied8984938" root="2.16.840.1.113883.3.67.933"/>
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| − | <assignedPerson>
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| − | <name>
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| − | <prefix qualifier="AC">Dr. med.</prefix>
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| − | <given>Theo</given>
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| − | <family>Phyllin</family>
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| − | </name>
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| − | </assignedPerson>
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| − | <representedOrganization>
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| − | <id extension="1443984938" root="BSNR"/>
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| − | <name>Praxis Dr. med. Phyllin</name>
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| − | <telecom use="WP" value="tel:0214.2127070"/>
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| − | <telecom use="WP" value="tel:0214.212707122"/>
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| − | <addr>
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| − | <streetName>Krankenhausstraße</streetName>
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| − | <houseNumber>240</houseNumber>
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| − | <postalCode>51371</postalCode>
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| − | <city>Leverkusen</city>
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| − | </addr>
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| − | </representedOrganization>
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| − | </assignedAuthor>
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| − | </author>
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| − | <custodian>
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| − | <assignedCustodian>
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| − | <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
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| − | <id extension="M345" root="1.2.276.0.58"/>
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| − | <name>Praxis Dr. med. Phyllin</name>
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| − | <telecom use="WP" value="tel:0214.2127070"/>
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| − | <addr>
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| − | <streetName>Krankenhausstraße</streetName>
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| − | <houseNumber>240</houseNumber>
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| − | <postalCode>51371</postalCode>
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| − | <city>Leverkusen</city>
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| − | </addr>
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| − | </representedCustodianOrganization>
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| − | </assignedCustodian>
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| − | </custodian>
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| − | <legalAuthenticator typeCode="LA" contextControlCode="OP">
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| − | <time value="20171004"/>
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| − | <signatureCode code="S"/>
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| − | <assignedEntity>
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| − | <!-- nur als ID (identisch zu author) -->
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| − | <id extension="ied8984938" root="2.16.840.1.113883.3.67.933"/>
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| − | </assignedEntity>
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| − | </legalAuthenticator>
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| − | <documentationOf typeCode="DOC">
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| − | <ServiceEvent classCode="ACT" moodCode="EVN">
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| − | <code code="xFOLGE_END" codeSystem="1.2.276.0.76.11.456" displayName="Folgebescheinigung AU"/>
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| − | </ServiceEvent>
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| − | </documentationOf>
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| − | <component>
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| − | <structuredBody>
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| − | <!-- Versicherung Section -->
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| − | <component typeCode="COMP" >
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| − | <section>
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| − | <templateId root="xxxxxx"/>
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| − | <code code="48768-0" codeSystem="2.16.840.1.113883.6.1"/>
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| − | <title>Versicherung</title>
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| − | <!-- Versicherung/Coverage -->
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| − | <entry>
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| − | <act classCode="ACT" moodCode="EVN">
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| − | <templateId/>
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| − | <id/>
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| − | <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" />
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| − | <statusCode code="completed"/>
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| − | <entryRelationship typeCode="COMP">
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| − | <!-- Versicherungspolicy -->
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| − | <act classCode="ACT" moodCode="EVN">
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| − | <templateId root="VERSICHERUNG" />
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| − | <code code="VERSICHERUNG" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
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| − | <statusCode code="completed"/>
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| − | <!-- Payer Information -->
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| − | <performer>
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| − | <assignedEntity>
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| − | <id extension="Kassen-ID-47" />
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| − | <addr>
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| − | <streetAddressLine>AOK-Weg 1459</streetAddressLine>
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| − | <postalCode>10111</postalCode>
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| − | <city>Berlin</city>
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| − | </addr>
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| − | <representedOrganization>
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| − | <name>Versicherung AOK Berlin</name>
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| − | </representedOrganization>
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| − | </assignedEntity>
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| − | </performer>
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| − | <!-- Guarantor -->
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| − | <!--
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| − | <performer modeCode="WRITTEN" />
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| − | -->
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| − | <!-- Versicherung -->
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| − | <participant typeCode="COV">
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| − | <time>
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| − | <high value="20181231"/>
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| − | </time>
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| − | <participantRole>
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| − | <!-- Versichertenstatus -->
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| − | <code code="1"/>
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| − | </participantRole>
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| − | </participant>
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| − | <!-- Versicherter -->
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| − | <participant typeCode="HLD">
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| − | <participantRole>
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| − | <id root="xxxxxxxxx" extension="VNR=4711" />
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| − | </participantRole>
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| − | </participant>
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| − | <entryRelationship typeCode="COMP" >
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| − | <!-- Person Group Observation -->
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| − | <observation classCode="OBS" moodCode="EVN" >
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| − | <templateId root="PRSNGRP" />
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| − | <code code="PRSNGRP" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
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| − | <!-- aus S_KBV_PERSONENGRUPPE -->
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| − | <value xsi:type="CD" code="4" codeSystem="1.2.276.0.76.11.151" displayName="SOZ"/>
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| − | </observation>
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| − | </entryRelationship>
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| − | <entryRelationship typeCode="COMP" >
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| − | <!-- DMP Observation -->
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| − | <observation classCode="OBS" moodCode="EVN">
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| − | <templateId root="DMP" />
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| − | <code code="DMP" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
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| − | <!-- aus S_KBV_DMP -->
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| − | <value xsi:type="CD" code="D" codeSystem="1.2.276.0.76.11.138"/>
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| − | </observation>
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| − | </entryRelationship>
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| − | <entryRelationship typeCode="COMP" >
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| − | <!-- DMP Observation -->
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| − | <observation classCode="OBS" moodCode="EVN">
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| − | <templateId root="ASV" />
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| − | <code code="ASV" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
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| − | <!-- aus S_KBV_ASV -->
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| − | <value xsi:type="CD" code="A" />
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| − | </observation>
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| − | </entryRelationship>
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| − | </act>
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| − | </entryRelationship>
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| − | </act>
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| − | </entry>
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| − | </section>
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| − | </component>
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| − | <!-- AU-Diagnose Section -->
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| − | <component>
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| − | <section>
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| − | <templateId root="xxxxxx"/>
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| − | <code code="AU-DIAGNOSIS" />
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| − | <title>AU-begründende Diagnosen</title>
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| − | <text>Der Patient will einfach nicht arbeiten!</text>
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| − | <entry>
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| − | <observation classCode="OBS" moodCode="EVN">
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| − | <code code="x47"/>
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| − | <statusCode code="completed"/>
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| − | </observation>
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| − | </entry>
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| − | <entry>
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| − | <observation classCode="OBS" moodCode="EVN">
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| − | <code code="x80"/>
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| − | <statusCode code="completed"/>
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| − | </observation>
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| − | </entry>
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| − | </section>
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| − | </component>
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| − | <!-- Findings Section -->
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| − | <component>
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| − | <section>
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| − | <templateId/>
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| − | <text>
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| − |
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| − | </text>
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| − | </section>
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| − | </component>
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| − | <!-- Accident/Unfall Section -->
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| − | <component>
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| − | <section>
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| − | <templateId/>
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| − | <code code="ACCIDENT"/>
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| − | <title>Unfall</title>
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| − | <entry>
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| − | <observation classCode="OBS" moodCode="EVN">
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| − | <templateId/>
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| − | <code code="ACCIDENT"/>
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| − | <statusCode code="completed"/>
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| − | <effectiveTime/>
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| − | <!-- aus S_KBV_01_Accident -->
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| − | <value xsi:type="CD" code="D-ARZT" codeSystem="1.2.276.0.76.3.1.135.8.11.4"/>
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| − | </observation>
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| − | </entry>
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| − | </section>
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| − | </component>
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| − | <!-- Treatment Section -->
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| − | <component>
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| − | <section>
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| − | <templateId/>
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| − | <code code="TREATMENT"/>
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| − | <title>Einleitung besonderer Maßnahmen</title>
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| − | <text>
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| − | keine Ahnung, was sonst noch zu tun ist
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| − | </text>
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| − | <!-- Treatment stufenweise Wiedereingliederung -->
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| − | <entry>
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| − | <observation classCode="OBS" moodCode="EVN">
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| − | <code code="EINGLIEDERUNG" />
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| − | <value xsi:type="BL" value="false"/>
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| − | </observation>
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| − | </entry>
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| − | <!-- Treatment Leistungen med. Reha Observation -->
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| − | <entry>
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| − | <observation classCode="OBS" moodCode="EVN">
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| − | <code code="REHA" />
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| − | <value xsi:type="BL" value="true"/>
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| − | </observation>
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| − | </entry>
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| − | </section>
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| − | </component>
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| − | <!-- Temporary Disablement Section -->
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| − | <component>
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| − | <section>
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| − | <templateId/>
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| − | <code code="TEMPDISABLE"/>
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| − | <title>Arbeitsunfähigkeit</title>
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| − | <entry>
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| − | <observation classCode="OBS" moodCode="EVN">
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| − | <code code="X-IATWRK" codeSystem="2.16.840.1.113883.6.1">
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| − | <qualifier>
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| − | <!-- auf für nach der 7. Woche -->
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| − | <name code="x7AU"/>
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| − | <value code="x7AU"/>
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| − | </qualifier>
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| − | </code>
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| − | <text>
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| − | beliebiger Text
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| − | </text>
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| − | <statusCode code="completed"/>
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| − | <effectiveTime>
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| − | <!-- Zeitraum der Arbeitsunfähigkeit -->
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| − | <low value="20171018"/>
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| − | <high value="20171020"/>
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| − | </effectiveTime>
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| − | <value xsi:type="PQ" unit="%" value="100" />
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| − | <performer>
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| − | <!-- festgestellt am -->
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| − | <time value="20171019"/>
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| − | <assignedEntity>
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| − | <id/>
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| − | <assignedPerson>
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| − | <name>Hugo Müller</name>
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| − | </assignedPerson>
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| − | </assignedEntity>
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| − | </performer>
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| − | </observation>
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| − | </entry>
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| − | </section>
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| − | </component>
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| − | </structuredBody>
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| − | </component>
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| − | </ClinicalDocument>
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| − | | |
| − | </syntaxhighlight>
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| − | | |
| − | | |
| − | [[Kategorie:cdaeau|Beispiel]]
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