cdapad:Symptomerfassung-Section (Template): Unterschied zwischen den Versionen
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[[Datei:Symptomerfassung_cda.png]] | [[Datei:Symptomerfassung_cda.png]] | ||
| + | {| class="hl7table" | ||
| + | ! Lvl | ||
| + | ! RIM | ||
| + | ! Name | ||
| + | ! DT | ||
| + | ! Kard | ||
| + | ! Conf | ||
| + | ! Beschreibung | ||
| + | |||
| + | |- | ||
| + | |1 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |Symptomerfassung | ||
| + | | | ||
| + | |null | ||
| + | |null | ||
| + | | | ||
| + | |||
| + | |- | ||
| + | |1 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |@classCode | ||
| + | |CS CNE | ||
| + | |1..1 | ||
| + | |M | ||
| + | |DOCSECT | ||
| + | |||
| + | |- | ||
| + | |1 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |@moodCode | ||
| + | |CS CNE | ||
| + | |1..1 | ||
| + | |M | ||
| + | |EVN | ||
| + | |||
| + | |- | ||
| + | |1 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |code | ||
| + | |CD CWE | ||
| + | |0..1 | ||
| + | |O | ||
| + | | | ||
| + | |||
| + | |- | ||
| + | |1 | ||
| + | |bgcolor="ffaaaa"|rel | ||
| + | |entry | ||
| + | | | ||
| + | |0..* | ||
| + | |O | ||
| + | | | ||
| + | |||
| + | |- | ||
| + | |2 | ||
| + | |bgcolor="ffaaaa"|rel | ||
| + | |@typeCode | ||
| + | |CS CNE | ||
| + | |1..1 | ||
| + | |M | ||
| + | | | ||
| + | |||
| + | |- | ||
| + | |2 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |Symptom | ||
| + | | | ||
| + | |0..* | ||
| + | |O | ||
| + | | | ||
| + | |||
| + | |- | ||
| + | |3 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |@classCode | ||
| + | |CS CNE | ||
| + | |1..1 | ||
| + | |M | ||
| + | |OBS | ||
| + | |||
| + | |- | ||
| + | |3 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |@moodCode | ||
| + | |CS CNE | ||
| + | |1..1 | ||
| + | |M | ||
| + | |EVN | ||
| + | |||
| + | |- | ||
| + | |3 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |code | ||
| + | |CD CWE | ||
| + | |0..1 | ||
| + | |O | ||
| + | | | ||
| + | |||
| + | |- | ||
| + | |3 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |text | ||
| + | |ED | ||
| + | |0..1 | ||
| + | |O | ||
| + | | | ||
| + | |||
| + | |- | ||
| + | |3 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |effectiveTime | ||
| + | |TS | ||
| + | |0..1 | ||
| + | |O | ||
| + | | | ||
| + | |||
| + | |- | ||
| + | |3 | ||
| + | |bgcolor="ff8888"|act | ||
| + | |value | ||
| + | |ANY CWE | ||
| + | |0..1 | ||
| + | |O | ||
| + | | | ||
| + | |||
| + | |||
| + | |} | ||
===Beispiel=== | ===Beispiel=== | ||
Version vom 3. März 2014, 15:59 Uhr
Section: Symptomerfassung
| Template-Metadaten | |
| Template-Typ | Section |
| Template ID | keine |
| generischeres Template | |
| genutztes Templates | |
| nutzende Templates | |
| abgeleitete Templates | |
| Schwester-Templates | |
| generelle Beschreibung | Sektion für Symptomerfassung |
| allg. Erläuterung | Sektion für Symptomerfassung |
| Verhältnis zu IHE | neu |
| Ballotierungsstatus | |
| Erweiterbarkeit | offen oder geschlossen |
Alle Symptome werden in dieser Sektion festgehalten. Wie in der nachfolgenden Abbildung zu erkennen, umfasst die Sektion Symptomerfassung eine beliebige Anzahl Einträge eines Symptoms in Form einer Observation-Klasse
| Lvl | RIM | Name | DT | Kard | Conf | Beschreibung |
|---|---|---|---|---|---|---|
| 1 | act | Symptomerfassung | null | null | ||
| 1 | act | @classCode | CS CNE | 1..1 | M | DOCSECT |
| 1 | act | @moodCode | CS CNE | 1..1 | M | EVN |
| 1 | act | code | CD CWE | 0..1 | O | |
| 1 | rel | entry | 0..* | O | ||
| 2 | rel | @typeCode | CS CNE | 1..1 | M | |
| 2 | act | Symptom | 0..* | O | ||
| 3 | act | @classCode | CS CNE | 1..1 | M | OBS |
| 3 | act | @moodCode | CS CNE | 1..1 | M | EVN |
| 3 | act | code | CD CWE | 0..1 | O | |
| 3 | act | text | ED | 0..1 | O | |
| 3 | act | effectiveTime | TS | 0..1 | O | |
| 3 | act | value | ANY CWE | 0..1 | O |
|
Beispiel
<section>
<code code="29547-7" codeSystem="LOINC" displayName=“Anamnese“ />
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<code xsi:type="CD" code="4.0" codeSystem="Palliativinhalte" codeSystemName="1.2.276.0.76.3.1.81.4.6.0" displayName="Symptom"/>
<effectiveTime value="20140201"/>
<value xsi:type="CD" code="4" codeSystem="1.2.276.0.76.3.1.81.4.6.4" codeSystemName="Symptome" displayName=”Luftnot”>
<qualifier>
<value code="5 " />
</qualifier>
</value>
<entryRelationship typeCode="COMP">
<!-- Neuer Eintrag! -->
</entryRelationship>
</observation>
</entry>
</section>
