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

Version vom 29. Juni 2020, 21:16 Uhr

Id 1.2.276.0.76.3.1.261.1.10.4.14 Gültigkeit 2018‑06‑04

Status Entwurf Versions-Label

Name DiagnoseObservation2 Anzeigename Diagnose 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".

Kontext Elternknoten des Template-Element mit Id 1.2.276.0.76.3.1.261.1.10.4.14

Klassifikation CDA Entry Level Template

Offen/Geschlossen Offen (auch andere als die definierten Elemente sind erlaubt)

Assoziiert mit

Assoziiert mit 3 Konzepte

Id	Name	Datensatz
dguvbbr-dataelement2-113	Jargondiagnose/Freitext	Stationärer Entlassungsbericht
dguvbbr-dataelement2-114	Code	Stationärer Entlassungsbericht
dguvbbr-dataelement2-115	Anzeigename	Stationärer Entlassungsbericht

Benutzt

Benutzt 1 Template

Benutzt	als	Name	Version
1.2.276.0.76.3.1.261.1.10.4.7	Containment	Klassifikation Observation	DYNAMIC

Beziehung

Version: 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">  </hl7:entryRelationship></hl7:observation>

Item DT Kard Konf Beschreibung Label

hl7:observation

(Dia...on2)

@classCode

cs

1 … 1

F

OBS

@moodCode

cs

1 … 1

F

EVN

hl7:templateId

1 … 1

M

(Dia...on2)

@root

uid

1 … 1

F

1.2.276.0.76.3.1.261.1.10.4.14

hl7:id

1 … *

(Dia...on2)

hl7:code

1 … 1

M

(Dia...on2)

@code

CONF

1 … 1

F

8651-2

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (LOINC)

@displayName

1 … 1

F

Hospital discharge Dx

hl7:text

ED

0 … 1

Textform, enthält hier lediglich reference in den Text der Section

(Dia...on2)

hl7:reference

URL

1 … 1

(Dia...on2)

@value

1 … 1

R

#diag-{generierteID}, z.B.: #diag-1

hl7:statusCode

1 … 1

M

(Dia...on2)

@code

CONF

1 … 1

F

completed

hl7:effectiveTime

1 … 1

R

Die 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)

hl7:low

1 … 1

R

Das low Element gibt das Datum an, seit wann der Patient diese Diagnose hat

(Dia...on2)

hl7:high

0 … 1

Das high Element gibt das Datum an, seit wann der Patient diese Diagnose nicht mehr hat

(Dia...on2)

hl7:value

CD

1 … 1

R

(Dia...on2)


dguvbbr-dataelement2-114	Code	Stationärer Entlassungsbericht
dguvbbr-dataelement2-115	Anzeigename	Stationärer Entlassungsbericht

hl7:originalText

ED

0 … 1

C

(Dia...on2)


	dguvbbr-dataelement2-113	Jargondiagnose/Freitext	Stationärer Entlassungsbericht

Beispiel <hl7:originalText>Hämatothorax links</hl7:originalText>

hl7:qualifier

CR

0 … 1

Unfallabhängige(s) Diagnose/Problem?

(Dia...on2)

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>

hl7:name

CV

1 … 1

M

(Dia...on2)

@code

CONF

1 … 1

F

ACCRELA

@codeSystem

1 … 1

F

1.2.276.0.76.3.1.261.1.10.5.100

hl7:value

CV

1 … 1

M

(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)

hl7:entryRelationship

0 … *

R

Beinhaltet 1.2.276.0.76.3.1.261.1.10.4.7 Klassifikation Observation (DYNAMIC)

(Dia...on2)

@typeCode

cs

1 … 1

F

COMP

Constraint

Wenn 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

Version vom 1. Juni 2019, 03:21 Uhr (Quelltext anzeigen) ADbot (Diskussion \| Beiträge) (Automated ADBot page content) ← Zum vorherigen Versionsunterschied		Version vom 29. Juni 2020, 21:16 Uhr (Quelltext anzeigen) ADbot (Diskussion \| Beiträge) (Automated ADBot page content) Zum nächsten Versionsunterschied →
Zeile 1:		Zeile 1:
−	<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-dataelement2-113</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-dataelement2-114</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-dataelement2-115</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"><</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">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">id</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">originalText</span><span class="ppsign">></span><span class="pptext">Schädelprellung</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">originalText</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">qualifier</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">qualifier</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span><br /><span style="display: block;"> <span style="color:green"><!-- template 1.2.276.0.76.3.1.261.1.10.4.7 'Klassifikation Observation' (2018-05-30T14:10:03) --><br /></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">entryRelationship</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">></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>anamnestisch einen Herzinfarkt erheben, der vor fünf Jahren stattgefunden</div><div>hat, ist effectiveTime: vor fünf Jahren.</div> 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. </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:low<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>Das low Element gibt das Datum an, seit wann der Patient diese Diagnose hat</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:high<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Das high Element gibt das Datum an, seit wann der Patient diese Diagnose nicht mehr hat</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:value<br /></strong></tt></td></tr></table></td><td><strong>CD</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></td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="3">[[File:Target.png\|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">dguvbbr-dataelement2-114</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem (ICD10) / ">[[File:Kyellow.png\|14px]] Code </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png\|14px]] Stationärer Entlassungsbericht </td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">dguvbbr-dataelement2-115</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem (ICD10) / ">[[File:Kyellow.png\|14px]] Anzeigename </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png\|14px]] Stationärer Entlassungsbericht </td></tr></table></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:originalText<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>C</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png\|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">dguvbbr-dataelement2-113</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Jargondiagnose / ">[[File:Kyellow.png\|14px]] Jargondiagnose/Freitext </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png\|14px]] Stationärer Entlassungsbericht </td></tr></table></td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Beispiel</td><td colspan="4" class="explabelblue"><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">originalText</span><span class="ppsign">></span><span class="pptext">Hämatothorax links</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">originalText</span><span class="ppsign">></span></span></tt></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:qualifier <br /></strong></tt></td></tr></table></td><td><strong>CR</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Unfallabhängige(s) Diagnose/Problem?</td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><~~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> wo <i> ~~[hl7:name~~/~~@code~~=~~'ACCRELA']</i~~><~~/td~~><~~/tr~~><~~/table~~></td><~~td></td~~></tr><tr class="~~explabel~~ " style="~~vertical-align~~: ~~top~~;"~~><td style~~="~~background-color: white;~~" ~~colspan~~="1"> </td><td>~~Beispiel~~</td><~~td colspan="4"~~ class="~~explabelblue~~"><tt><span ~~style~~="~~display: block;~~" ~~class~~="~~explrendered"~~><span class="~~ppsign~~">~~<~~</span><span class="~~ppelement~~">~~qualifier~~</span><span class="~~ppsign~~">~~>~~</span~~><br /~~><span ~~style~~="~~display: block;~~" ~~class~~="~~explrendered"~~> <span class="~~ppsign~~">~~<~~</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="~~ppattribute~~">~~displayName~~</span><span class="ppsign">="</span><span class="ppcontent">~~Unfallabhängigkeit Diagnose/Problem~~</span><span class="ppsign">"</span><span class="~~ppsign~~">/</span><span class="ppsign">~~>~~</span></span><span ~~style~~="~~display: block;~~" ~~class="explrendered~~"> <span class="ppsign">~~<~~</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~~="~~ppsign~~">/<~~/span~~><~~span class~~="~~ppsign~~">~~>~~</~~span~~><~~/span><span class~~="~~ppsign~~">~~</~~</~~span~~><~~span class~~="~~ppnamespace~~"></~~span><span class="ppelement">qualifier</span~~><~~span class="ppsign"~~>~~>~~<~~/span~~><~~/span~~></tt></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:Treeblank.png\|16px]]<~~/td><td style="~~vertical~~-~~align~~: ~~top~~;">~~[[File:Treetree~~.~~png\|16px]]~~</td><td><~~tt><strong>hl7:name<br~~ /><~~/strong></tt~~></td><~~/tr></~~table~~></td><td><strong>CV</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: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>@code<br~~ /><~~/strong></tt></~~td>~~</tr></table>~~</td><td ~~rowspan~~="2" ~~class="conf">CONF~~</td><td><~~span style="color: black;"~~><strong>~~1 … 1~~</~~strong~~></~~span~~></td><td><~~strong~~>F</~~strong~~></td><td ~~colspan~~="2">~~ACCRELA~~</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: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>~~@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"~~>~~1.2.276.0.76.3.1.261.1.10.5.100~~</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:Treeblank.png\|16px]]~~</td><td ~~style~~="~~vertical-align: top;">[[File:Treetree.png\|16px]]~~</td><td><~~tt><strong>hl7~~:~~value~~<~~br /></strong~~><~~/tt></~~td><~~/tr></table></td~~><td><~~strong~~>CV</~~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 style="~~background-~~color: ~~white~~;" ~~colspan="1"~~> </td><~~td class="conf"~~>~~CONF~~</td><td ~~colspan="4"~~><~~table class~~="~~artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background~~: ~~transparent~~;"><~~tr style="vertical-align: top;"~~><td>~~Der Wert von @code muss gewählt werden aus dem Value Set 1.2~~.276.0.76.3.1.261.1.11.11 <i>~~Typisierung Unfallabhängkeit (DGUV)~~ </i>(DYNAMIC)</td><~~/tr></table></~~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:entryRelationship<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … </strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.276.0.76.3.1.261.1.10.4.7 <i>Klassifikation Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png\|16px]]</td><td> wo <i> [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)]]]</i></td></tr></table></td><td></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>@typeCode<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">COMP</td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4">Wenn die Diagnose laut ICD-10 eine Fraktur ist und eine AO-Klassifikation hat, soll die AO-Klassifikation auch angegeben werden<br /><table class="artdecor" style="background: transparent;"><tr><th colspan="1" rowspan="1">Region/Klasse</th><th colspan="1" rowspan="1">Code inkl. aller Unterklassen</th></tr><tr><td colspan="1" rowspan="1">S02.- Fraktur des Schädels und der Gesichtsschädelknochen</td><td colspan="1" rowspan="1">S02.0 - S02.09</td></tr><tr><td colspan="1" rowspan="1">S12.- Fraktur im Bereich des Halses</td><td colspan="1" rowspan="1">S12.0 - S12.9</td></tr><tr><td colspan="1" rowspan="1">S22.- Fraktur der Rippe(n), des Sternums und der Brustwirbelsäule</td><td colspan="1" rowspan="1">S22.0 - S22.9</td></tr><tr><td colspan="1" rowspan="1">S32.- Fraktur der Lendenwirbelsäule und des Beckens</td><td colspan="1" rowspan="1">S32.0 - S32.89</td></tr><tr><td colspan="1" rowspan="1">S42.- Fraktur im Bereich der Schulter und des Oberarmes</td><td colspan="1" rowspan="1">S42.0 - S42.9</td></tr><tr><td colspan="1" rowspan="1">S52.- Fraktur des Unterarmes</td><td colspan="1" rowspan="1">S52.0 - S52.9</td></tr><tr><td colspan="1" rowspan="1">S62.- Fraktur im Bereich des Handgelenkes und der Hand</td><td colspan="1" rowspan="1">S62.0 - S62.8</td></tr><tr><td colspan="1" rowspan="1">S72.- Fraktur des Femurs</td><td colspan="1" rowspan="1">S72.0 - S72.9</td></tr><tr><td colspan="1" rowspan="1">S82.- Fraktur des Unterschenkels, einschließlich des oberen Sprunggelenkes</td><td colspan="1" rowspan="1">S82.0 - S82.9</td></tr><tr><td colspan="1" rowspan="1">S92.- Fraktur des Fußes [ausgenommen oberes Sprunggelenk]</td><td colspan="1" rowspan="1">S92.0 - S92.9</td></tr><tr><td colspan="1" rowspan="1">T02.- Frakturen mit Beteiligung mehrerer Körperregionen</td><td colspan="1" rowspan="1">T02.0 - T02.91</td></tr><tr><td colspan="1" rowspan="1">T08.- Fraktur der Wirbelsäule, Höhe nicht näher bezeichnet</td><td colspan="1" rowspan="1">T08.0 - T08.1</td></tr><tr><td colspan="1" rowspan="1">T10.- Fraktur der oberen Extremität, Höhe nicht näher bezeichnet</td><td colspan="1" rowspan="1">T10.0 - T10.1</td></tr><tr><td colspan="1" rowspan="1">T12.- Fraktur der unteren Extremität, Höhe nicht näher bezeichnet</td><td colspan="1" rowspan="1">T12.0 - T12.1</td></tr><tr><td colspan="1" rowspan="1">T14.- Verletzung an einer nicht näher bezeichneten Körperregion</td><td colspan="1" rowspan="1">T14.2 - T14.21</td></tr><tr><td colspan="1" rowspan="1">M80.- Osteoporose mit pathologischer Fraktur</td><td colspan="1" rowspan="1">M80.0 - M80.99</td></tr></table></td></tr></table></td></tr></table>	+	<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-dataelement2-113</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-dataelement2-114</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-dataelement2-115</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"><</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">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">id</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">originalText</span><span class="ppsign">></span><span class="pptext">Schädelprellung</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">originalText</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">qualifier</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">qualifier</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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">></span><br /><span style="display: block;"> <span style="color:green"><!-- template 1.2.276.0.76.3.1.261.1.10.4.7 'Klassifikation Observation' (2018-05-30T14:10:03) --><br /></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">entryRelationship</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">></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>anamnestisch einen Herzinfarkt erheben, der vor fünf Jahren stattgefunden</div><div>hat, ist effectiveTime: vor fünf Jahren.</div> 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. </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:low<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>Das low Element gibt das Datum an, seit wann der Patient diese Diagnose hat</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:high<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Das high Element gibt das Datum an, seit wann der Patient diese Diagnose nicht mehr hat</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:value<br /></strong></tt></td></tr></table></td><td><strong>CD</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></td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="3">[[File:Target.png\|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">dguvbbr-dataelement2-114</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem (ICD10) / ">[[File:Kyellow.png\|14px]] Code </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png\|14px]] Stationärer Entlassungsbericht </td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">dguvbbr-dataelement2-115</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem (ICD10) / ">[[File:Kyellow.png\|14px]] Anzeigename </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png\|14px]] Stationärer Entlassungsbericht </td></tr></table></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:originalText<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>C</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png\|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;">dguvbbr-dataelement2-113</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Jargondiagnose / ">[[File:Kyellow.png\|14px]] Jargondiagnose/Freitext </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png\|14px]] Stationärer Entlassungsbericht </td></tr></table></td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Beispiel</td><td colspan="4" class="explabelblue"><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">originalText</span><span class="ppsign">></span><span class="pptext">Hämatothorax links</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">originalText</span><span class="ppsign">></span></span></tt></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:qualifier <br /></strong></tt></td></tr></table></td><td><strong>CR</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Unfallabhängige(s) Diagnose/Problem?</td><td style="background-color: #FFEEEE;"><span title="">(Dia...on2)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [hl7:name/@code='ACCRELA']</i></td><td></td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Beispiel</td><td colspan="4" class="explabelblue"><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">qualifier</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</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="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Unfallabhängigkeit Diagnose/Problem</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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="ppsign">/</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">qualifier</span><span class="ppsign">></span></span></tt></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:Treeblank.png\|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>hl7:name<br /></strong></tt></td></tr></table></td><td><strong>CV</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: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>@code<br /></strong></tt></td></tr></table></td><td rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">ACCRELA</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: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>@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">1.2.276.0.76.3.1.261.1.10.5.100</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:Treeblank.png\|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>hl7:value<br /></strong></tt></td></tr></table></td><td><strong>CV</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 style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.276.0.76.3.1.261.1.11.11 <i>Typisierung Unfallabhängkeit (DGUV) </i>(DYNAMIC)</td></tr></table></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:entryRelationship<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … </strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.276.0.76.3.1.261.1.10.4.7 <i>Klassifikation Observation</i> (DYNAMIC)</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>@typeCode<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">COMP</td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4">Wenn die Diagnose laut ICD-10 eine Fraktur ist und eine AO-Klassifikation hat, soll die AO-Klassifikation auch angegeben werden<br /><table class="artdecor" style="background: transparent;"><tr><th colspan="1" rowspan="1">Region/Klasse</th><th colspan="1" rowspan="1">Code inkl. aller Unterklassen</th></tr><tr><td colspan="1" rowspan="1">S02.- Fraktur des Schädels und der Gesichtsschädelknochen</td><td colspan="1" rowspan="1">S02.0 - S02.09</td></tr><tr><td colspan="1" rowspan="1">S12.- Fraktur im Bereich des Halses</td><td colspan="1" rowspan="1">S12.0 - S12.9</td></tr><tr><td colspan="1" rowspan="1">S22.- Fraktur der Rippe(n), des Sternums und der Brustwirbelsäule</td><td colspan="1" rowspan="1">S22.0 - S22.9</td></tr><tr><td colspan="1" rowspan="1">S32.- Fraktur der Lendenwirbelsäule und des Beckens</td><td colspan="1" rowspan="1">S32.0 - S32.89</td></tr><tr><td colspan="1" rowspan="1">S42.- Fraktur im Bereich der Schulter und des Oberarmes</td><td colspan="1" rowspan="1">S42.0 - S42.9</td></tr><tr><td colspan="1" rowspan="1">S52.- Fraktur des Unterarmes</td><td colspan="1" rowspan="1">S52.0 - S52.9</td></tr><tr><td colspan="1" rowspan="1">S62.- Fraktur im Bereich des Handgelenkes und der Hand</td><td colspan="1" rowspan="1">S62.0 - S62.8</td></tr><tr><td colspan="1" rowspan="1">S72.- Fraktur des Femurs</td><td colspan="1" rowspan="1">S72.0 - S72.9</td></tr><tr><td colspan="1" rowspan="1">S82.- Fraktur des Unterschenkels, einschließlich des oberen Sprunggelenkes</td><td colspan="1" rowspan="1">S82.0 - S82.9</td></tr><tr><td colspan="1" rowspan="1">S92.- Fraktur des Fußes [ausgenommen oberes Sprunggelenk]</td><td colspan="1" rowspan="1">S92.0 - S92.9</td></tr><tr><td colspan="1" rowspan="1">T02.- Frakturen mit Beteiligung mehrerer Körperregionen</td><td colspan="1" rowspan="1">T02.0 - T02.91</td></tr><tr><td colspan="1" rowspan="1">T08.- Fraktur der Wirbelsäule, Höhe nicht näher bezeichnet</td><td colspan="1" rowspan="1">T08.0 - T08.1</td></tr><tr><td colspan="1" rowspan="1">T10.- Fraktur der oberen Extremität, Höhe nicht näher bezeichnet</td><td colspan="1" rowspan="1">T10.0 - T10.1</td></tr><tr><td colspan="1" rowspan="1">T12.- Fraktur der unteren Extremität, Höhe nicht näher bezeichnet</td><td colspan="1" rowspan="1">T12.0 - T12.1</td></tr><tr><td colspan="1" rowspan="1">T14.- Verletzung an einer nicht näher bezeichneten Körperregion</td><td colspan="1" rowspan="1">T14.2 - T14.21</td></tr><tr><td colspan="1" rowspan="1">M80.- Osteoporose mit pathologischer Fraktur</td><td colspan="1" rowspan="1">M80.0 - M80.99</td></tr></table></td></tr></table></td></tr></table>

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

Version vom 29. Juni 2020, 21:16 Uhr

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