cdapad:Pflegedokumentation-Section (Template): Unterschied zwischen den Versionen
(→Section: Pflegedokumentation) |
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[[Datei:Pflegedokumentation_cda.png]] | [[Datei:Pflegedokumentation_cda.png]] | ||
+ | {| class="hl7table" | ||
+ | ! Lvl | ||
+ | ! RIM | ||
+ | ! Name | ||
+ | ! DT | ||
+ | ! Kard | ||
+ | ! Conf | ||
+ | ! Beschreibung | ||
+ | |||
+ | |- | ||
+ | |1 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |Pflegedokumentation | ||
+ | | | ||
+ | |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 | ||
+ | | | ||
+ | |1..1 | ||
+ | |R | ||
+ | | | ||
+ | |||
+ | |- | ||
+ | |2 | ||
+ | |bgcolor="ffaaaa"|rel | ||
+ | |@typeCode | ||
+ | |CS CNE | ||
+ | |1..1 | ||
+ | |M | ||
+ | | | ||
+ | |||
+ | |- | ||
+ | |2 | ||
+ | |bgcolor="ff8888"|act | ||
+ | |Pflegedokumentation | ||
+ | | | ||
+ | |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 | ||
+ | |CW 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 | ||
+ | | | ||
+ | |||
+ | |||
+ | |} | ||
Version vom 3. März 2014, 16:06 Uhr
Section: Pflegedokumentation
Template-Metadaten | |
Template-Typ | Section |
Template ID | keine |
generischeres Template | - |
genutztes Templates | - |
nutzende Templates | - |
abgeleitete Templates | - |
Schwester-Templates | - |
generelle Beschreibung | Pflegedokumentation |
allg. Erläuterung | Sektion Pflegedokumentation |
Verhältnis zu IHE | neu |
Ballotierungsstatus | in Abstimmung |
Erweiterbarkeit | offen |
Die Pflegedokumentation wird in der Section „Pflegedokumentation“ festgehalten. Hier können Informationen zur Patientenpflege hinterlegt werden, welche eine Relevanz für das PalliativCareTeam haben.
Lvl | RIM | Name | DT | Kard | Conf | Beschreibung |
---|---|---|---|---|---|---|
1 | act | Pflegedokumentation | 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 | 1..1 | R | ||
2 | rel | @typeCode | CS CNE | 1..1 | M | |
2 | act | Pflegedokumentation | 0..* | O | ||
3 | act | @classCode | CS CNE | 1..1 | M | OBS |
3 | act | @moodCode | CS CNE | 1..1 | M | EVN |
3 | act | code | CW 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="Pflegedokumentation" codeSystem="LOINC" />
<entry typeCode="DRIV">
<observation classCode="OBS" moodCode="EVN">
<code xsi:type="CD" code="5.0" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="Pflegedokumentation"/>
<effectiveTime value="20140201" />
<value xsi:type="CD" code="4" codeSystem="1.2.276.0.76.3.1.81.4.6.5" codeSystemName="Problembereiche" displayName=”Ausscheidung”/>
<entryRelationship typeCode="COMP">
<!-- Neuer Eintrag -->
</entryRelationship>
</observation>
</entry>
</section>