1.2.276.0.76.10.4075/static-2015-12-06T000000

Id	1.2.276.0.76.10.4075	Gültigkeit	2015‑12‑06
Status	Entwurf	Versions-Label
Name	ProblemObservation	Anzeigename	Problem Observation
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".
Kontext	Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4075
Klassifikation	CDA Entry Level Template
Offen/Geschlossen	Offen (auch andere als die definierten Elemente sind erlaubt)
Benutzt	Benutzt 6 Templates Benutzt als Name Version 1.2.276.0.76.10.90025 Inklusion Author (Body) DYNAMIC 1.2.276.0.76.10.4077 Containment Alter Beobachtung DYNAMIC 1.2.276.0.76.10.4078 Containment Prognose Observation DYNAMIC 1.2.276.0.76.10.4076 Containment Priorität Präferenz DYNAMIC 1.2.276.0.76.10.4093 Containment Manifestation Observation DYNAMIC 1.2.276.0.76.10.4094 Containment Etiology Observation 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)
Beispiel	Beispiel <observation classCode="OBS" moodCode="EVN">   <!-- Problem Observation -->   <templateId root="1.2.276.0.76.10.4075"/>  <id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>  <code code="29308-4" 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 dieses Problem hat -->     <low value="20130703"/>    <!-- Das high Element gibt das Datum an, seit wann der Patient dieses Problem nicht mehr hat -->     <high value="20130721"/>  </effectiveTime>  <!-- Im value Element wird das Problem angegeben. Dies kann ein ICD 10 Code oder ein anderer Code sein. -->   <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 des Problem -->   </author></observation>
Item DT Kard Konf Beschreibung Label hl7:observation (Pro...ion) @classCode cs 1 … 1 F OBS @moodCode cs 1 … 1 F EVN @negationInd bl 0 … 1   hl7:templateId 1 … 1 M (Pro...ion) @root uid 1 … 1 F 1.2.276.0.76.10.4075 hl7:id 1 … * (Pro...ion) hl7:code 1 … 1 M (Pro...ion)   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.3.88.12.3221.7.2 Problem Type (DYNAMIC) hl7:statusCode 1 … 1 M (Pro...ion) @code CONF 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. (Pro...ion) hl7:low 1 … 1 M Das low Element gibt das Datum an, seit wann der Patient diese Problem hat (Pro...ion) hl7:high 0 … 1 Das high Element gibt das Datum an, seit wann der Patient diese Problem nicht mehr hat (Pro...ion) hl7:value CD 1 … 1 R (Pro...ion)   CONF muss aus der Konzeptdomäne "Problemcodes" 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. (Pro...ion) hl7:translation 0 … * (Pro...ion) @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 (Pro...ion) Eingefügt von 1.2.276.0.76.10.90025 Author (Body) (DYNAMIC) @typeCode 0 … 1 F AUT @context​Control​Code 0 … 1 F OP hl7:functionCode CE 0 … 1 (Pro...ion)   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 (Pro...ion) hl7:assignedAuthor 1 … 1 R (Pro...ion) @classCode 0 … 1 F ASSIGNED hl7:id II 1 … * R (Pro...ion) hl7:code CE 0 … 1 (Pro...ion) @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.111 (Role Code) hl7:addr AD 0 … * (Pro...ion) hl7:telecom TEL 0 … * (Pro...ion) hl7:assigned​Person 0 … 1 (Pro...ion) 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 M (Pro...ion) hl7:represented​Organization 0 … 1 (Pro...ion) 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 … * (Pro...ion) hl7:name ON 1 … 1 M (Pro...ion) hl7:telecom TEL 0 … * (Pro...ion) hl7:addr AD 0 … 1 (Pro...ion) hl7:entryRelationship 0 … 1 Alter des Patienten Beinhaltet 1.2.276.0.76.10.4077 Alter Beobachtung (DYNAMIC) (Pro...ion) wo [hl7:observation [hl7:code [(@code = '30525-0' and @codeSystem = '2.16.840.1.113883.6.1')]]] @typeCode cs 1 … 1 F SUBJ @inversionInd bl 1 … 1 F true hl7:entryRelationship 0 … 1 Prognose des Problems Beinhaltet 1.2.276.0.76.10.4078 Prognose Observation (DYNAMIC) (Pro...ion) wo [hl7:observation [hl7:code [(@code = '75328-5' and @codeSystem = '2.16.840.1.113883.6.1')]]] @typeCode cs 1 … 1 F REFR hl7:entryRelationship 0 … * Schweregrad des Problems laut Einschätzung des Gesundheitsdienstleisters Beinhaltet 1.2.276.0.76.10.4076 Priorität Präferenz (DYNAMIC) (Pro...ion) wo [hl7:observation [hl7:code [(@code = '77303-6' and @codeSystem = '2.16.840.1.113883.6.1')]]] @typeCode cs 1 … 1 F REFR hl7:entryRelationship 0 … * Manifestations-Beobachtung Beinhaltet 1.2.276.0.76.10.4093 Manifestation Observation (DYNAMIC) (Pro...ion) wo [hl7:observation [hl7:code [(@code = '75328-5' and @codeSystem = '2.16.840.1.113883.6.1')]]] @typeCode cs 1 … 1 F MFST hl7:entryRelationship 0 … * Ätiologie-Beobachtung Beinhaltet 1.2.276.0.76.10.4094 Etiology Observation (DYNAMIC) (Pro...ion) wo [hl7:observation [hl7:code [(@code = '75328-5' and @codeSystem = '2.16.840.1.113883.6.1')]]] @typeCode cs 1 … 1 F CAUS