| <tmp1 xmlns="">Id</tmp1> | 1.2.276.0.76.10.4074 | <tmp1 xmlns="">Gültigkeit</tmp1> | 2015‑12‑06 |
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| <tmp1 xmlns="">Status</tmp1> |  Entwurf | <tmp1 xmlns="">Versions-Label</tmp1> | |
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| <tmp1 xmlns="">Name</tmp1> | ProblemConcernAct | <tmp1 xmlns="">Anzeigename</tmp1> | Problem Concern Act |
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| <tmp1 xmlns="">Beschreibung</tmp1> |  This template reflects an ongoing concern on behalf of the provider that placed the concern on a patient’s problem list. So long as the underlying condition is of concern to the provider (i.e., as long as the condition, whether active or resolved, is of ongoing concern and interest to the provider), the statusCode is “active”. Only when the underlying condition is no longer of concern is the statusCode set to “completed”. The effectiveTime reflects the time that the underlying condition was felt to be a concern; it may or may not correspond to the effectiveTime of the condition (e.g., even five years later, the clinician may remain concerned about a prior heart attack). The statusCode of the Problem Concern Act is the definitive indication of the status of the concern, whereas the effectiveTime of the nested Problem Observation is the definitive indication of whether or not the underlying condition is resolved. The effectiveTime/low of the Problem Concern Act asserts when the concern became active. This equates to the time the concern was authored in the patient's chart. The effectiveTime/high asserts when the concern was completed (e.g., when the clinician deemed there is no longer any need to track the underlying condition). A Problem Concern Act can contain many Problem Observations (templateId 2.16.840.1.113883.10.20.22.4.4). Each Problem Observation is a discrete observation of a condition, and therefore will have a statusCode of “completed”. The many Problem Observations nested under a Problem Concern Act reflect the change in the clinical understanding of a condition over time. For instance, a Concern may initially contain a Problem Observation of “chest pain”: - Problem Concern 1 --- Problem Observation: Chest Pain Later, a new Problem Observation of “esophagitis” will be added, reflecting a better understanding of the nature of the chest pain. The later problem observation will have a more recent author time stamp. - Problem Concern 1 --- Problem Observation (author/time Jan 3, 2012): Chest Pain --- Problem Observation (author/time Jan 6, 2012): Esophagitis Many systems display the nested Problem Observation with the most recent author time stamp, and provide a mechanism for viewing prior observations. |
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| <tmp1 xmlns="">Kontext</tmp1> | Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4074 |
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| <tmp1 xmlns="">Klassifikation</tmp1> | CDA Entry Level Template |
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| <tmp1 xmlns="">Offen/Geschlossen</tmp1> | <tmp1 xmlns="">Offen (auch andere als die definierten Elemente sind erlaubt)</tmp1> |
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| <tmp1 xmlns="">Benutzt</tmp1> | | <tmp1 xmlns="">Benutzt</tmp1> <tmp1 xmlns="">3 Templates</tmp1> | | <tmp1 xmlns="">Benutzt</tmp1> | <tmp1 xmlns=""> als </tmp1> | <tmp1 xmlns="">Name</tmp1> | <tmp1 xmlns="">Version</tmp1> |
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| 1.2.276.0.76.10.90025 | <tmp1 xmlns="">Inklusion</tmp1> | Author (Body) | <tmp1 xmlns="">DYNAMIC</tmp1> | | 1.2.276.0.76.10.4075 | <tmp1 xmlns="">Containment</tmp1> | Problem Observation | <tmp1 xmlns="">DYNAMIC</tmp1> | | 1.2.276.0.76.10.4076 | <tmp1 xmlns="">Containment</tmp1> | Priorität Präferenz | <tmp1 xmlns="">DYNAMIC</tmp1> |
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| <tmp1 xmlns="">Beziehung</tmp1> | Spezialisierung: <tmp1 xmlns="">Template</tmp1> <tmp1 xmlns="">2.16.840.1.113883.10.12.301 (2005‑09‑07)</tmp1>
Adaptation: <tmp1 xmlns="">Template</tmp1> <tmp1 xmlns="">2.16.840.1.113883.10.20.22.4.3 (2015‑08‑01)</tmp1> |
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| <tmp1 xmlns="">Beispiel</tmp1> | | <tmp1 xmlns="">Beispiel</tmp1> | <act classCode="ACT" moodCode="EVN">
<templateId root="1.2.276.0.76.10.4074"/> <id root="ec8a6ff8-ed4b-4f7e-82c3-e98e58b45de7"/> <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/> <!-- Der statusCode besagt, dass das Problem noch besteht (aktuell/aktiv) und verfolgt werden muss -->
<statusCode code="active"/> <effectiveTime>
<!-- Das low Element gibt an, wann das Problem zum ersten Male dokumentiert worden ist -->
<low value="201307061145-0800"/> </effectiveTime> <author typeCode="AUT">
<!-- dasselbe wie Concern effectiveTime/low -->
<time value="201307061145-0800"/> <assignedAuthor>
<!-- Autor des Problems mit id und code -->
</assignedAuthor> </author> <entryRelationship typeCode="SUBJ">
<observation classCode="OBS" moodCode="EVN">
<!-- Problem Observation 1.2.276.0.76.10.4076 -->
</observation> </entryRelationship></act> |
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| <tmp1 xmlns="">Item</tmp1> | <tmp1 xmlns="">DT</tmp1> | <tmp1 xmlns="">Kard</tmp1> | <tmp1 xmlns="">Konf</tmp1> | <tmp1 xmlns="">Beschreibung</tmp1> | <tmp1 xmlns="">Label</tmp1> |
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| | | | | (Pro...Act) |  | @classCode
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| cs | 1 … 1 | F | ACT | | @moodCode
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| cs | 1 … 1 | F | EVN | | hl7:templateId
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| | 1 … 1 | M | | (Pro...Act) |  | | @root
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| uid | 1 … 1 | F | 1.2.276.0.76.10.4074 | | hl7:id
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| | 1 … * | | | (Pro...Act) | | hl7:code
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| | 1 … 1 | M | | (Pro...Act) | | | @code
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| CONF | 1 … 1 | F | CONC | | | @codeSystem
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| 1 … 1 | F | 2.16.840.1.113883.5.6<tmp1 xmlns=""> (HL7ActClass)</tmp1> | | hl7:statusCode
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| | 1 … 1 | M | | (Pro...Act) | | hl7:effectiveTime
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| | 1 … 1 | M | | (Pro...Act) | | | hl7:low
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| | 1 … 1 | M | | (Pro...Act) | | | hl7:high
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| | 0 … 1 | | | (Pro...Act) | | hl7:author
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| | 0 … * | R | | (Pro...Act) | | <tmp1 xmlns="">Eingefügt</tmp1> | | | <tmp1 xmlns=""> von </tmp1>1.2.276.0.76.10.90025 Author (Body) (<tmp1 xmlns="">DYNAMIC</tmp1>) | | | @typeCode
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| | 0 … 1 | F | AUT | | | @contextControlCode
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| | 0 … 1 | F | OP | | | hl7:functionCode
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| CE | 0 … 1 | | | (Pro...Act) | | | CONF | | <tmp1 xmlns="">Der Wert von @code muss gewählt werden aus dem Value Set </tmp1>2.16.840.1.113883.1.11.10267 ParticipationFunction (<tmp1 xmlns="">DYNAMIC</tmp1>) |
| | | hl7:time
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| TS | 1 … 1 | R | | (Pro...Act) | | | hl7:assignedAuthor
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| | 1 … 1 | R | | (Pro...Act) | | | 0 … 1 | F | ASSIGNED | | II | 1 … * | R | | (Pro...Act) | | CE | 0 … 1 | | | (Pro...Act) | | CONF | 0 … 1 | F | 2.16.840.1.113883.5.111<tmp1 xmlns=""> (Role Code)</tmp1> | | AD | 0 … * | | | (Pro...Act) | | TEL | 0 … * | | | (Pro...Act) | | | 0 … 1 | | | (Pro...Act) | | <tmp1 xmlns="">Eingefügt</tmp1> | | | <tmp1 xmlns=""> von </tmp1>1.2.276.0.76.10.90010 CDA Person Elements (<tmp1 xmlns="">DYNAMIC</tmp1>) | | | 0 … 1 | F | PSN | | | 0 … 1 | F | INSTANCE | | PN | 1 … 1 | M | | (Pro...Act) | | | | hl7:representedOrganization
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| | 0 … 1 | | | (Pro...Act) | | <tmp1 xmlns="">Eingefügt</tmp1> | | | <tmp1 xmlns=""> von </tmp1>1.2.276.0.76.10.90011 CDA Organization Elements (<tmp1 xmlns="">DYNAMIC</tmp1>) | | | 0 … 1 | F | ORG | | | 0 … 1 | F | INSTANCE | | II | 0 … * | | | (Pro...Act) | | ON | 1 … 1 | M | | (Pro...Act) | | TEL | 0 … * | | | (Pro...Act) | | AD | 0 … 1 | | | (Pro...Act) | | hl7:entryRelationship
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| | 1 … * | M | Liste der Probleme
<tmp1 xmlns="">Beinhaltet</tmp1> 1.2.276.0.76.10.4075 Problem Observation (<tmp1 xmlns="">DYNAMIC</tmp1>) | (Pro...Act) | | <tmp1 xmlns=""> wo </tmp1> [hl7:observation [hl7:code [concat(@code, @codeSystem) = doc('include/voc-2.16.840.1.113883.3.88.12.3221.7.2-DYNAMIC.xml')//valueSet [1]/conceptList/concept/concat(@code, @codeSystem)]]] |
| | | | @typeCode
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| cs | 1 … 1 | F | SUBJ | | hl7:entryRelationship
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| | 0 … * | | Priorität des Problem laut Einschätzung des Gesundheitsdienstleisters
<tmp1 xmlns="">Beinhaltet</tmp1> 1.2.276.0.76.10.4076 Priorität Präferenz (<tmp1 xmlns="">DYNAMIC</tmp1>) | (Pro...Act) | | <tmp1 xmlns=""> wo </tmp1> [hl7:observation [hl7:code [(@code = '77303-6' and @codeSystem = '2.16.840.1.113883.6.1')]]] |
| | | | @typeCode
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| cs | 1 … 1 | F | REFR |
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Entwurf
