1.2.276.0.76.3.1.261.1.10.4.14/static-2018-06-04T000000: Unterschied zwischen den Versionen

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<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.276.0.76.3.1.261.1.10.4.14</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2018‑06‑04</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Entwurf</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;"></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">DiagnoseObservation2</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Diagnose Observation</td></tr><td style="text-align: left;" colspan="4"><table class="treetable" id="templateDescTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Beschreibung</td></tr><tr><td><div>Dieses Template spiegelt eine konkrete Beobachtung über das Problem bzw. die Diagnose eines Patienten wider. Weil es sich um eine abgeschlossene Beobachtung handelt, ist der statusCode immer "completed". </div></td></tr></table></td><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Kontext</th><td style="text-align: left;" colspan="3">Elternknoten des Template-Element mit Id 1.2.276.0.76.3.1.261.1.10.4.14</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Entry Level Template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Offen/Geschlossen</th><td style="text-align: left;" colspan="3">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Assoziiert mit</th><td style="text-align: left;" colspan="3"><table class="treetable" id="assocsTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Assoziiert mit 3 Konzepte</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Id</th><th style="width: 60%; text-align: left;">Name</th><th style="width: 20%; text-align: left;">Datensatz</th></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;">dguvbbr-data&#8203;element2-113</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Jargondiagnose / ">[[File:Kyellow.png|14px]] Jargondiagnose/Freitext </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Stationärer Entlassungsbericht  </td></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;">dguvbbr-data&#8203;element2-114</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem (ICD10) / ">[[File:Kyellow.png|14px]] Code </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Stationärer Entlassungsbericht  </td></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;">dguvbbr-data&#8203;element2-115</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem (ICD10) / ">[[File:Kyellow.png|14px]] Anzeigename </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Stationärer Entlassungsbericht  </td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Benutzt</th><td style="text-align: left;" colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt 1 Template</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Benutzt</th><th style="width: 1%; text-align: left;"> als </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.2.276.0.76.3.1.261.1.10.4.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Klassifikation Observation</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beziehung</th><td style="text-align: left;" colspan="3">Version: Template 1.2.276.0.76.10.4080 <i>Diagnose Observation </i> (2015‑12‑06) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">hl7de-</div></span><br />Spezialisierung: Template 2.16.840.1.113883.10.12.303 <i>CDA Observation </i> (2005‑09‑07) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">ad1bbr-</div></span><br />Adaptation: Template 2.16.840.1.113883.10.20.22.4.4 <i> </i> (2015‑08‑01) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">?</div></span><br />Spezialisierung: Template 1.2.276.0.76.10.4075 <i>Problem Observation </i> (2015‑12‑06) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">hl7de-</div></span></td></tr><tr class="explabel " style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelblue"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Beispiel Jargondiagnose und ggfls. Klassifikation</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">OBS</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.3.1.261.1.10.4.14</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">id</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">8651-2</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Hospital discharge Dx</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#diag-1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">completed</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20190128</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">CD</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span><span class="pptext">Schädelprellung</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">name</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">ACCRELA</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.3.1.261.1.10.5.100</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">RACC</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.3.1.261.1.5.11</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Diagnose/Problem unfallabhäng</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.2.276.0.76.3.1.261.1.10.4.7 'Klassifikation Observation' (2018-05-30T14:10:03) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Kard</th><th style="width: 2em; text-align: left;">Konf</th><th style="text-align: left;">Beschreibung</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:observation<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">OBS</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@moodCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.276.0.76.3.1.261.1.10.4.14</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:code<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@code<br /></strong></tt></td></tr></table></td><td rowspan="3" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">8651-2</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.6.1 (LOINC)</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@displayName<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">Hospital discharge Dx</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:text<br /></strong></tt></td></tr></table></td><td><strong>ED</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Textform, enthält hier lediglich reference in den Text der Section</td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:reference<br /></strong></tt></td></tr></table></td><td><strong>URL</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@value<br /></strong></tt></td></tr></table></td><td></td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2">#diag-{generierteID}, z.B.: #diag-1</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:statusCode<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@code<br /></strong></tt></td></tr></table></td><td rowspan="1" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">completed</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:effectiveTime<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Die effectiveTime wird auch als "biologisch relevante Zeit" bezeichnet und ist der Zeitpunkt oder Zeitraum, für den die Beobachtung für den Patienten gilt.<br />
+
<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.276.0.76.3.1.261.1.10.4.14</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2018‑06‑04</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Entwurf</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;"></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">DiagnoseObservation2</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Diagnose Observation</td></tr><td style="text-align: left;" colspan="4"><table class="treetable" id="templateDescTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Beschreibung</td></tr><tr><td><div>Dieses Template spiegelt eine konkrete Beobachtung über das Problem bzw. die Diagnose eines Patienten wider. Weil es sich um eine abgeschlossene Beobachtung handelt, ist der statusCode immer "completed". </div></td></tr></table></td><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Kontext</th><td style="text-align: left;" colspan="3">Elternknoten des Template-Element mit Id 1.2.276.0.76.3.1.261.1.10.4.14</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Entry Level Template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Offen/Geschlossen</th><td style="text-align: left;" colspan="3">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Assoziiert mit</th><td style="text-align: left;" colspan="3"><table class="treetable" id="assocsTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Assoziiert mit 3 Konzepte</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Id</th><th style="width: 60%; text-align: left;">Name</th><th style="width: 20%; text-align: left;">Datensatz</th></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;">dguvbbr-data&#8203;element2-113</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Jargondiagnose / ">[[File:Kyellow.png|14px]] Jargondiagnose/Freitext </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Stationärer Entlassungsbericht  </td></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;">dguvbbr-data&#8203;element2-114</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem (ICD10) / ">[[File:Kyellow.png|14px]] Code </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Stationärer Entlassungsbericht  </td></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;">dguvbbr-data&#8203;element2-115</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem (ICD10) / ">[[File:Kyellow.png|14px]] Anzeigename </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Stationärer Entlassungsbericht  </td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Benutzt</th><td style="text-align: left;" colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt 1 Template</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Benutzt</th><th style="width: 1%; text-align: left;"> als </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.2.276.0.76.3.1.261.1.10.4.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Klassifikation Observation</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beziehung</th><td style="text-align: left;" colspan="3">Version: Template 1.2.276.0.76.10.4080 <i>Diagnose Observation </i> (2015‑12‑06) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">hl7de-</div></span><br />Spezialisierung: Template 2.16.840.1.113883.10.12.303 <i>CDA Observation </i> (2005‑09‑07) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">ad1bbr-</div></span><br />Adaptation: Template 2.16.840.1.113883.10.20.22.4.4 <i>Problem Observation (V3) </i> (2015‑08‑01) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">ccda-</div></span><br />Spezialisierung: Template 1.2.276.0.76.10.4075 <i>Problem Observation </i> (2015‑12‑06) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">hl7de-</div></span></td></tr><tr class="explabel " style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelblue"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Beispiel Jargondiagnose und ggfls. Klassifikation</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">OBS</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.3.1.261.1.10.4.14</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">id</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">8651-2</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Hospital discharge Dx</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#diag-1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">completed</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20190128</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">CD</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span><span class="pptext">Schädelprellung</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">name</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">ACCRELA</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.3.1.261.1.10.5.100</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">RACC</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.3.1.261.1.5.11</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Diagnose/Problem unfallabhäng</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.2.276.0.76.3.1.261.1.10.4.7 'Klassifikation Observation' (2018-05-30T14:10:03) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Kard</th><th style="width: 2em; text-align: left;">Konf</th><th style="text-align: left;">Beschreibung</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:observation<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">OBS</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@moodCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.276.0.76.3.1.261.1.10.4.14</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:code<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@code<br /></strong></tt></td></tr></table></td><td rowspan="3" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">8651-2</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.6.1 (LOINC)</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@displayName<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">Hospital discharge Dx</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:text<br /></strong></tt></td></tr></table></td><td><strong>ED</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Textform, enthält hier lediglich reference in den Text der Section</td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:reference<br /></strong></tt></td></tr></table></td><td><strong>URL</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@value<br /></strong></tt></td></tr></table></td><td></td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2">#diag-{generierteID}, z.B.: #diag-1</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:statusCode<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@code<br /></strong></tt></td></tr></table></td><td rowspan="1" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">completed</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:effectiveTime<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Die effectiveTime wird auch als "biologisch relevante Zeit" bezeichnet und ist der Zeitpunkt oder Zeitraum, für den die Beobachtung für den Patienten gilt.<br />
 
<div>Beispiel: Für Gesundheitsdienstleister, die einen Patienten heute in der Klinik sehen,</div>
 
<div>Beispiel: Für Gesundheitsdienstleister, die einen Patienten heute in der Klinik sehen,</div>
 
<div>anamnestisch einen Herzinfarkt erheben, der vor fünf Jahren stattgefunden</div>
 
<div>anamnestisch einen Herzinfarkt erheben, der vor fünf Jahren stattgefunden</div>

Version vom 14. März 2019, 04:20 Uhr

Id1.2.276.0.76.3.1.261.1.10.4.14Gültigkeit2018‑06‑04
StatusKyellow.png EntwurfVersions-Label
NameDiagnoseObservation2AnzeigenameDiagnose Observation
Beschreibung
Dieses Template spiegelt eine konkrete Beobachtung über das Problem bzw. die Diagnose eines Patienten wider. Weil es sich um eine abgeschlossene Beobachtung handelt, ist der statusCode immer "completed".
KontextElternknoten des Template-Element mit Id 1.2.276.0.76.3.1.261.1.10.4.14
KlassifikationCDA Entry Level Template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Assoziiert mit
Assoziiert mit 3 Konzepte
IdNameDatensatz
dguvbbr-data​element2-113Kyellow.png Jargondiagnose/Freitext Kyellow.png Stationärer Entlassungsbericht
dguvbbr-data​element2-114Kyellow.png Code Kyellow.png Stationärer Entlassungsbericht
dguvbbr-data​element2-115Kyellow.png Anzeigename Kyellow.png Stationärer Entlassungsbericht
Benutzt
Benutzt 1 Template
Benutzt als NameVersion
1.2.276.0.76.3.1.261.1.10.4.7ContainmentKyellow.png Klassifikation ObservationDYNAMIC
BeziehungVersion: Template 1.2.276.0.76.10.4080 Diagnose Observation (2015‑12‑06)
ref
hl7de-

Spezialisierung: Template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-

Adaptation: Template 2.16.840.1.113883.10.20.22.4.4 Problem Observation (V3) (2015‑08‑01)
ref
ccda-

Spezialisierung: Template 1.2.276.0.76.10.4075 Problem Observation (2015‑12‑06)
ref
hl7de-
Beispiel
Beispiel Jargondiagnose und ggfls. Klassifikation
<hl7:observation classCode="OBS" moodCode="EVN">
  <hl7:templateId root="1.2.276.0.76.3.1.261.1.10.4.14"/>  <hl7:id/>  <hl7:code code="8651-2" codeSystem="2.16.840.1.113883.6.1" displayName="Hospital discharge Dx"/>  <hl7:text>
    <hl7:reference value="#diag-1"/>  </hl7:text>  <hl7:statusCode code="completed"/>  <hl7:effectiveTime>
    <hl7:low value="20190128"/>  </hl7:effectiveTime>  <hl7:value xsi:type="CD">
    <hl7:originalText>Schädelprellung</hl7:originalText>    <hl7:qualifier>
      <hl7:name code="ACCRELA" codeSystem="1.2.276.0.76.3.1.261.1.10.5.100"/>      <hl7:value code="RACC" codeSystem="1.2.276.0.76.3.1.261.1.5.11" displayName="Diagnose/Problem unfallabhäng"/>    </hl7:qualifier>  </hl7:value>  <hl7:entryRelationship typeCode="COMP">
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ItemDTKardKonfBeschreibungLabel
hl7:observation
(Dia...on2)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
1 … 1M(Dia...on2)
Treeblank.pngTreetree.png@root
uid1 … 1F1.2.276.0.76.3.1.261.1.10.4.14
Treetree.pnghl7:id
1 … *(Dia...on2)
Treetree.pnghl7:code
1 … 1M(Dia...on2)
Treeblank.pngTreetree.png@code
CONF1 … 1F8651-2
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treeblank.pngTreetree.png@displayName
1 … 1FHospital discharge Dx
Treetree.pnghl7:text
ED0 … 1Textform, enthält hier lediglich reference in den Text der Section(Dia...on2)
Treeblank.pngTreetree.pnghl7:reference
URL1 … 1(Dia...on2)
Treeblank.pngTreeblank.pngTreetree.png@value
1 … 1R#diag-{generierteID}, z.B.: #diag-1
Treetree.pnghl7:statusCode
1 … 1M(Dia...on2)
Treeblank.pngTreetree.png@code
CONF1 … 1Fcompleted
Treetree.pnghl7:effectiveTime
1 … 1RDie effectiveTime wird auch als "biologisch relevante Zeit" bezeichnet und ist der Zeitpunkt oder Zeitraum, für den die Beobachtung für den Patienten gilt.
Beispiel: Für Gesundheitsdienstleister, die einen Patienten heute in der Klinik sehen,
anamnestisch einen Herzinfarkt erheben, der vor fünf Jahren stattgefunden
hat, ist effectiveTime: vor fünf Jahren.
Die effectiveTime hier ist die definitive Angabe, ob die zugrunde liegende Erkrankung behoben ist. effectiveTime.low ist der Beginn des Problems für den Patienten. Wenn das Problem noch nicht gelöst ist, wird effectiveTime.high nicht gesetzt. Wenn bekannt ist, dass das Problem gelöst worden ist, dann ist effectiveTime.high vorhanden. Wenn der genaue Zeitpunkt der Lösung des Problems nicht bekannt ist, dann ist effectiveTime.high vorhanden und auf nullFlavor "UNK" gesetzt. 		(Dia...on2)
Treeblank.pngTreetree.pnghl7:low
1 … 1RDas low Element gibt das Datum an, seit wann der Patient diese Diagnose hat(Dia...on2)
Treeblank.pngTreetree.pnghl7:high
0 … 1Das high Element gibt das Datum an, seit wann der Patient diese Diagnose nicht mehr hat(Dia...on2)
Treetree.pnghl7:value
CD1 … 1R(Dia...on2)
 
Target.png
dguvbbr-data​element2-114Kyellow.png Code Kyellow.png Stationärer Entlassungsbericht
dguvbbr-data​element2-115Kyellow.png Anzeigename Kyellow.png Stationärer Entlassungsbericht
Treeblank.pngTreetree.pnghl7:originalText
ED0 … 1C(Dia...on2)
 
Target.png
dguvbbr-data​element2-113Kyellow.png Jargondiagnose/Freitext Kyellow.png Stationärer Entlassungsbericht
 Beispiel<hl7:originalText>Hämatothorax links</hl7:originalText>
Treeblank.pngTreetree.pnghl7:qualifier
CR0 … 1Unfallabhängige(s) Diagnose/Problem?(Dia...on2)
Treeblank.pngTreeblank.png wo [hl7:name/​@code​=​'ACCRELA']
 Beispiel<qualifier>
  <name code="ACCRELA" codeSystem="1.2.276.0.76.3.1.261.1.10.5.100" displayName="Unfallabhängigkeit Diagnose/Problem"/>  <value code="RACC" codeSystem="1.2.276.0.76.3.1.261.1.5.11"/></qualifier>
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV1 … 1M(Dia...on2)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF1 … 1FACCRELA
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 … 1F1.2.276.0.76.3.1.261.1.10.5.100
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CV1 … 1M(Dia...on2)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 1.2.276.0.76.3.1.261.1.11.11 Typisierung Unfallabhängkeit (DGUV) (DYNAMIC)
Treetree.pnghl7:entryRelationship
0 … *RBeinhaltet 1.2.276.0.76.3.1.261.1.10.4.7 Klassifikation Observation (DYNAMIC)(Dia...on2)
Treeblank.png wo [hl7:observation [hl7:code [concat(@code, @codeSystem) = doc('include/voc-1.2.276.0.76.3.1.261.1.11.8-DYNAMIC.xml')//valueSet [1]/conceptList/concept/concat(@code, @codeSystem)]]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
 ConstraintWenn die Diagnose laut ICD-10 eine Fraktur ist und eine AO-Klassifikation hat, soll die AO-Klassifikation auch angegeben werden
Region/Klasse Code inkl. aller Unterklassen
S02.- Fraktur des Schädels und der Gesichtsschädelknochen S02.0 - S02.09
S12.- Fraktur im Bereich des Halses S12.0 - S12.9
S22.- Fraktur der Rippe(n), des Sternums und der Brustwirbelsäule S22.0 - S22.9
S32.- Fraktur der Lendenwirbelsäule und des Beckens S32.0 - S32.89
S42.- Fraktur im Bereich der Schulter und des Oberarmes S42.0 - S42.9
S52.- Fraktur des Unterarmes S52.0 - S52.9
S62.- Fraktur im Bereich des Handgelenkes und der Hand S62.0 - S62.8
S72.- Fraktur des Femurs S72.0 - S72.9
S82.- Fraktur des Unterschenkels, einschließlich des oberen Sprunggelenkes S82.0 - S82.9
S92.- Fraktur des Fußes [ausgenommen oberes Sprunggelenk] S92.0 - S92.9
T02.- Frakturen mit Beteiligung mehrerer Körperregionen T02.0 - T02.91
T08.- Fraktur der Wirbelsäule, Höhe nicht näher bezeichnet T08.0 - T08.1
T10.- Fraktur der oberen Extremität, Höhe nicht näher bezeichnet T10.0 - T10.1
T12.- Fraktur der unteren Extremität, Höhe nicht näher bezeichnet T12.0 - T12.1
T14.- Verletzung an einer nicht näher bezeichneten Körperregion T14.2 - T14.21
M80.- Osteoporose mit pathologischer Fraktur M80.0 - M80.99
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