1.2.276.0.76.10.3058/static-2015-04-24T000000: Unterschied zwischen den Versionen

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                     <br xmlns="http://www.w3.org/1999/xhtml" />Offen:<br xmlns="http://www.w3.org/1999/xhtml" />Einweisungsdiagnose entspricht nicht zwangsläufig Aufnahmediagnose -&gt; admission diagnosis LOINC daher ggf. nicht zutreffend<br xmlns="http://www.w3.org/1999/xhtml" />Existiert ein LOINC Code für "referral diagnosis"?<br xmlns="http://www.w3.org/1999/xhtml" />
 
                     <br xmlns="http://www.w3.org/1999/xhtml" />Offen:<br xmlns="http://www.w3.org/1999/xhtml" />Einweisungsdiagnose entspricht nicht zwangsläufig Aufnahmediagnose -&gt; admission diagnosis LOINC daher ggf. nicht zutreffend<br xmlns="http://www.w3.org/1999/xhtml" />Existiert ein LOINC Code für "referral diagnosis"?<br xmlns="http://www.w3.org/1999/xhtml" />
 
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                 </td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Benutzt von / Benutzt</th><td xmlns="" style="vertical-align: top;" colspan="3"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td xmlns="" style="height: 30px;" colspan="2">Benutzt von / Benutzt 1 Template</td></tr><tr><td xmlns="" colspan="2"><div><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Benutzt von Template-Id</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 xmlns="" style="text-align: left;">1.2.276.0.76.10.1016</td><td xmlns="" style="text-align: left;"></td><td xmlns="" style="text-align: left;">AerztlicherKurzberichtKrankenhaus90a <i xmlns="http://www.w3.org/1999/xhtml">Ärztlicher Kurzbericht vom Krankenhaus nach §90a SGB V</i></td><td xmlns="" style="text-align: left;">2015‑03‑27</td></tr></table></div></td></tr></table></td></tr><tr><th style="text-align: left;">Beziehung</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">Spezialisierung: Template 2.16.840.1.113883.10.12.201 (<i xmlns="http://www.w3.org/1999/xhtml">2005‑09‑07</i>)</td></tr><tr class="explabel" style="vertical-align: top;"><td xmlns="">Beispiel</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">section</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.3058</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><br /></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">46241-6</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">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><br /></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">title</span><span class="ppsign">&gt;</span><span class="pptext">Einweisungsdiagnosen ärztlicher Kurzbericht</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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="ppelement">table</span> <span class="ppattribute">border</span><span class="ppsign">="</span><span class="ppcontent">2</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">thead</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span> <span class="ppattribute">width</span><span class="ppsign">="</span><span class="ppcontent">20%</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Einweisungsdiagnose</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span> <span class="ppattribute">width</span><span class="ppsign">="</span><span class="ppcontent">7%</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">J21.1</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span> <span class="ppattribute">width</span><span class="ppsign">="</span><span class="ppcontent">3%</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">-</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span> <span class="ppattribute">width</span><span class="ppsign">="</span><span class="ppcontent">3%</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">-</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Akute Bronchiolitis durch humanes Metapneumovirus</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">thead</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">tbody</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Nebendiagnose</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">J31.1</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">V</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">-</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">V.a. Allergische Rhinopathie durch Pollen</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Nebendiagnose</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">M23.3</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">-</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">R</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Sonstige Meniskusschädigungen Rechts</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">tbody</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">table</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr><td xmlns="" colspan="2" class="tabtab"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="6" style="background: transparent;"><tr><th style="width: 1%; text-align: left;">Item</th><th style="width: 1%; text-align: left;">DT</th><th style="width: 1%; text-align: left;">Kard</th><th style="width: 1%; text-align: left;">Konf</th><th style="text-align: left;">Beschreibung</th><th style="width: 1%; text-align: left;">Label</th></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:section<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml"></strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong></strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong></strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Einweisungsdiagnose)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">II</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Einweisungsdiagnose)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@root<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">1.2.276.0.76.10.3058</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:code<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">CE</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Einweisungsdiagnose)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@code<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">46241-6</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@codeSystemName<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">LOINC</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:title<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">ST</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Einweisungsdiagnose)</td></tr><tr style="vertical-align: top; background-color: #FFEEEE;"><td xmlns="" style="background-color: white"> </td><td xmlns="" style="vertical-align: top;" class="conf">CONF </td><td xmlns="" colspan="4" style="background-color: white"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td xmlns="">Elementinhalt muss "Einweisungsdiagnose" sein</td></tr></table></td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:text<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">SD.TEXT</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns="">Textfeld ist gemäß Beispiel zu strukturieren</td><td xmlns="" style="background-color: #FFEEEE">(Einweisungsdiagnose)</td></tr></table></td></tr></table>
+
                 </td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Benutzt von / Benutzt</th><td xmlns="" style="vertical-align: top;" colspan="3"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td xmlns="" style="height: 30px;" colspan="2">Benutzt von / Benutzt 2 Templates</td></tr><tr><td xmlns="" colspan="2"><div><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Benutzt von Template-Id</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 xmlns="" style="text-align: left;">1.2.276.0.76.10.1016</td><td xmlns="" style="text-align: left;">Containment</td><td xmlns="" style="text-align: left;">AerztlicherKurzberichtKrankenhaus90a <i xmlns="http://www.w3.org/1999/xhtml">Ärztlicher Kurzbericht vom Krankenhaus nach §90a SGB V</i></td><td xmlns="" style="text-align: left;">2015‑03‑27</td></tr><tr><td xmlns="" style="text-align: left;">1.2.276.0.76.10.1017</td><td xmlns="" style="text-align: left;">Containment</td><td xmlns="" style="text-align: left;">AerztlicherKurzberichtNiedergelassenerArzt90a <i xmlns="http://www.w3.org/1999/xhtml">Ärztlicher Kurzbericht Niedergelassener Arzt nach §90a SGB V</i></td><td xmlns="" style="text-align: left;">2015‑12‑11</td></tr></table></div></td></tr></table></td></tr><tr><th style="text-align: left;">Beziehung</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">Spezialisierung: Template 2.16.840.1.113883.10.12.201 (<i xmlns="http://www.w3.org/1999/xhtml">2005‑09‑07</i>)</td></tr><tr class="explabel" style="vertical-align: top;"><td xmlns="">Beispiel</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">section</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.3058</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><br /></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">46241-6</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">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span><br /></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">title</span><span class="ppsign">&gt;</span><span class="pptext">Einweisungsdiagnosen ärztlicher Kurzbericht</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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="ppelement">table</span> <span class="ppattribute">border</span><span class="ppsign">="</span><span class="ppcontent">2</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">thead</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span> <span class="ppattribute">width</span><span class="ppsign">="</span><span class="ppcontent">20%</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Einweisungsdiagnose</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span> <span class="ppattribute">width</span><span class="ppsign">="</span><span class="ppcontent">7%</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">J21.1</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span> <span class="ppattribute">width</span><span class="ppsign">="</span><span class="ppcontent">3%</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">-</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span> <span class="ppattribute">width</span><span class="ppsign">="</span><span class="ppcontent">3%</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">-</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Akute Bronchiolitis durch humanes Metapneumovirus</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">thead</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">tbody</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Nebendiagnose</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">J31.1</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">V</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">-</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">V.a. Allergische Rhinopathie durch Pollen</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Nebendiagnose</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">M23.3</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">-</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">center</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">R</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span> <span class="ppattribute">align</span><span class="ppsign">="</span><span class="ppcontent">left</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Sonstige Meniskusschädigungen Rechts</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">tbody</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">table</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</span><span class="ppsign">&gt;</span></span></tt></td></tr><tr><td xmlns="" colspan="2" class="tabtab"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="6" style="background: transparent;"><tr><th style="width: 1%; text-align: left;">Item</th><th style="width: 1%; text-align: left;">DT</th><th style="width: 1%; text-align: left;">Kard</th><th style="width: 1%; text-align: left;">Konf</th><th style="text-align: left;">Beschreibung</th><th style="width: 1%; text-align: left;">Label</th></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:section<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml"></strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong></strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong></strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Einweisungsdiagnose)</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">II</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Einweisungsdiagnose)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@root<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">1.2.276.0.76.10.3058</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:code<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">CE</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Einweisungsdiagnose)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@code<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">46241-6</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)</td></tr><tr><td xmlns=""><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treeblank.png|16px]]</td><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>@codeSystemName<br /></strong></tt></td></tr></table></td><td xmlns=""></td><td xmlns="">1 .. 1</td><td xmlns="">F</td><td xmlns="" colspan="2">LOINC</td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:title<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">ST</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns=""></td><td xmlns="" style="background-color: #FFEEEE">(Einweisungsdiagnose)</td></tr><tr style="vertical-align: top; background-color: #FFEEEE;"><td xmlns="" style="background-color: white"> </td><td xmlns="" style="vertical-align: top;" class="conf">CONF </td><td xmlns="" colspan="4" style="background-color: white"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td xmlns="">Elementinhalt muss "Einweisungsdiagnose" sein</td></tr></table></td></tr><tr style="background-color: #FFEAEA;"><td xmlns="" style="vertical-align: top;"><table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" cellpadding="1" style="background: transparent;"><tr><td xmlns="" style="vertical-align: top;">[[Datei:Treetree.png|16px]]</td><td xmlns=""><tt xmlns="http://www.w3.org/1999/xhtml"><strong>hl7:text<br /></strong></tt></td></tr></table></td><td xmlns="" style="vertical-align: top;"><strong xmlns="http://www.w3.org/1999/xhtml">SD.TEXT</strong></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>1 .. 1</strong></span></td><td xmlns="" style="vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: black;"><strong>M</strong></span></td><td xmlns="">Textfeld ist gemäß Beispiel zu strukturieren</td><td xmlns="" style="background-color: #FFEEEE">(Einweisungsdiagnose)</td></tr></table></td></tr></table>

Version vom 28. Dezember 2015, 21:47 Uhr

Template Einweisungsdiagnose
Id1.2.276.0.76.10.3058
Version gültig ab 2015‑04‑24 Status Kyellow.png In Entwicklung
KlassifikationCDA Section level template
KontextElternknoten des Template-Element mit Id 1.2.276.0.76.10.3058
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
BeschreibungWird verwendet in
  • ärztlicher Kurzbericht über den Krankenhausaufenthalt
  • ärztlicher Kurzbericht vom niedergelassenen Arzt
                   
Feldbezeichnungen auf dem Papierdokument: Einweisungsdiagnose bzw. Nebendiagnosen
                   

                   
Offen:
Einweisungsdiagnose entspricht nicht zwangsläufig Aufnahmediagnose -> admission diagnosis LOINC daher ggf. nicht zutreffend
Existiert ein LOINC Code für "referral diagnosis"?
Benutzt von / Benutzt
Benutzt von / Benutzt 2 Templates
Benutzt von Template-Id als NameVersion
1.2.276.0.76.10.1016ContainmentAerztlicherKurzberichtKrankenhaus90a Ärztlicher Kurzbericht vom Krankenhaus nach §90a SGB V2015‑03‑27
1.2.276.0.76.10.1017ContainmentAerztlicherKurzberichtNiedergelassenerArzt90a Ärztlicher Kurzbericht Niedergelassener Arzt nach §90a SGB V2015‑12‑11
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Beispiel<section>
  <templateId root="1.2.276.0.76.10.3058"/>
  <code code="46241-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
  <title>Einweisungsdiagnosen ärztlicher Kurzbericht</title>  <text>
    <table border="2">
      <thead>
        <tr>
          <td align="left" width="20%">Einweisungsdiagnose</td>          <td align="left" width="7%">J21.1</td>          <td align="center" width="3%">-</td>          <td align="center" width="3%">-</td>          <td align="left">Akute Bronchiolitis durch humanes Metapneumovirus</td>        </tr>      </thead>      <tbody>
        <tr>
          <td align="left">Nebendiagnose</td>          <td align="left">J31.1</td>          <td align="center">V</td>          <td align="center">-</td>          <td align="left">V.a. Allergische Rhinopathie durch Pollen</td>        </tr>        <tr>
          <td align="left">Nebendiagnose</td>          <td align="left">M23.3</td>          <td align="center">-</td>          <td align="center">R</td>          <td align="left">Sonstige Meniskusschädigungen Rechts</td>        </tr>      </tbody>    </table>  </text></section>
ItemDTKardKonfBeschreibungLabel
hl7:section
(Einweisungsdiagnose)
Treetree.pnghl7:templateId
II1 .. 1M(Einweisungsdiagnose)
Treeblank.pngTreetree.png@root
1 .. 1F1.2.276.0.76.10.3058
Treetree.pnghl7:code
CE1 .. 1M(Einweisungsdiagnose)
Treeblank.pngTreetree.png@code
1 .. 1F46241-6
Treeblank.pngTreetree.png@codeSystem
1 .. 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@codeSystemName
1 .. 1FLOINC
Treetree.pnghl7:title
ST1 .. 1M(Einweisungsdiagnose)
 CONF
Elementinhalt muss "Einweisungsdiagnose" sein
Treetree.pnghl7:text
SD.TEXT1 .. 1MTextfeld ist gemäß Beispiel zu strukturieren(Einweisungsdiagnose)
Abgerufen von „https://wiki.hl7.de/index.php?title=1.2.276.0.76.10.3058/static-2015-04-24T000000&oldid=28020“