1.2.276.0.76.10.3060/static-2015-04-29T000000: Unterschied zwischen den Versionen

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<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="border:1px solid #C0C0C0; width: 107pt; text-align: left;"><strong>Template </strong></th><td xmlns="" style="text-align: left; background-color: #F6F3EE">Befunde bei Entlassung<i> / BefundebeiEntlassung</i></td></tr><tr><th style="text-align: left;">Id</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">1.2.276.0.76.10.3060</td></tr><tr><th style="text-align: left;"> Version </th><td xmlns="" style="text-align: left; background-color: #F6F3EE"> gültig ab 2015‑04‑29 Status [[Datei:Kyellow.png|16px]] In Entwicklung</td></tr><tr><th style="text-align: left;">Klassifikation</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">CDA Section level template</td></tr><tr><th style="text-align: left;">Kontext</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">Elternknoten des Template-Element mit Id 1.2.276.0.76.10.3060</td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Offen/Geschlossen</th><td xmlns="" style="background-color: #F6F3EE">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Beschreibung</th><td xmlns="">Wird verwendet in<ul xmlns="http://www.w3.org/1999/xhtml">
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<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="border:1px solid #C0C0C0; width: 107pt; text-align: left;"><strong>Template </strong></th><td xmlns="" style="text-align: left; background-color: #F6F3EE">Befunde bei Entlassung<i> / BefundebeiEntlassung</i></td></tr><tr><th style="text-align: left;">Id</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">1.2.276.0.76.10.3060</td></tr><tr><th style="text-align: left;"> Version </th><td xmlns="" style="text-align: left; background-color: #F6F3EE"> gültig ab 2015‑04‑29 Status [[Datei:Kyellow.png|16px]] In Entwicklung</td></tr><tr><th style="text-align: left;">Klassifikation</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">CDA Section level template</td></tr><tr><th style="text-align: left;">Kontext</th><td xmlns="" style="text-align: left; background-color: #F6F3EE">Elternknoten des Template-Element mit Id 1.2.276.0.76.10.3060</td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Offen/Geschlossen</th><td xmlns="" style="background-color: #F6F3EE">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="text-align: left;">Beschreibung</th><td xmlns="">Feldbezeichnung auf dem Papierdokument: <u xmlns="http://www.w3.org/1999/xhtml">Entlassungsbefund</u>
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                        <li>ärztliche Kurzbericht über den Krankenhausaufenthalt</li>
 
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                    </ul>
 
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                    <br xmlns="http://www.w3.org/1999/xhtml" />Feldbezeichnung auf dem Papierdokument: <u xmlns="http://www.w3.org/1999/xhtml">Entlassungsbefund</u>
 
 
                     <br xmlns="http://www.w3.org/1999/xhtml" />
 
                     <br xmlns="http://www.w3.org/1999/xhtml" />
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                     <br xmlns="http://www.w3.org/1999/xhtml" />Section in Anlehnung an "Hospital Discharge Studies Summary Section" (CCDA)<br xmlns="http://www.w3.org/1999/xhtml" />
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                     <br xmlns="http://www.w3.org/1999/xhtml" />Section in Anlehnung an "Hospital Discharge Studies Summary Section" (C-CDA)<br xmlns="http://www.w3.org/1999/xhtml" />
 
                     <br xmlns="http://www.w3.org/1999/xhtml" />
 
                     <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 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>)<br xmlns="http://www.w3.org/1999/xhtml" />Adaptation: Template 2.16.840.1.113883.10.20.22.2.16 (<i xmlns="http://www.w3.org/1999/xhtml">DYNAMIC</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">1.2.276.0.76.10.3060</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">11493-4</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">Zusammenfassung der Befunde bei Entlassung</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">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">width</span><span class="ppsign">="</span><span class="ppcontent">20%</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Entlassungbefund</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="ppsign">&gt;</span><span class="pptext">Jetzt sind alle Untersuchten Werte im grünen Bereich</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">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">(BefundebeiEntlassung)</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">(BefundebeiEntlassung)</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">1.2.276.0.76.10.3060</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">(BefundebeiEntlassung)</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">11493-4</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">(BefundebeiEntlassung)</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 "Zusammenfassung der Befunde bei Entlassung" 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">(BefundebeiEntlassung)</td></tr></table></td></tr></table>
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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;">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></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>)<br xmlns="http://www.w3.org/1999/xhtml" />Adaptation: Template 2.16.840.1.113883.10.20.22.2.16 (<i xmlns="http://www.w3.org/1999/xhtml">DYNAMIC</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">1.2.276.0.76.10.3060</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">11493-4</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">Zusammenfassung der Befunde bei Entlassung</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">0</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">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="ppsign">&gt;</span><span class="pptext">Entlassungbefund</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="ppsign">&gt;</span><span class="pptext">Körpertemperatur 37.9°C, ø verstärkten Atemgeräusche, ø Tachypnoe</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">(BefundebeiEntlassung)</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">(BefundebeiEntlassung)</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">1.2.276.0.76.10.3060</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:id<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>0 .. 1</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">(BefundebeiEntlassung)</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">(BefundebeiEntlassung)</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">11493-4</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">(BefundebeiEntlassung)</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 "Zusammenfassung der Befunde bei Entlassung" 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">(BefundebeiEntlassung)</td></tr></table></td></tr></table>

Version vom 30. Dezember 2015, 08:36 Uhr

Template Befunde bei Entlassung / BefundebeiEntlassung
Id1.2.276.0.76.10.3060
Version gültig ab 2015‑04‑29 Status Kyellow.png In Entwicklung
KlassifikationCDA Section level template
KontextElternknoten des Template-Element mit Id 1.2.276.0.76.10.3060
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
BeschreibungFeldbezeichnung auf dem Papierdokument: Entlassungsbefund 
                   

                   
Section in Anlehnung an "Hospital Discharge Studies Summary Section" (C-CDA)
Benutzt von / Benutzt
Benutzt von / Benutzt 1 Template
Benutzt von Template-Id als NameVersion
1.2.276.0.76.10.1016ContainmentAerztlicherKurzberichtKrankenhaus90a Ärztlicher Kurzbericht vom Krankenhaus nach §90a SGB V2015‑03‑27
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Adaptation: Template 2.16.840.1.113883.10.20.22.2.16 (DYNAMIC)
Beispiel<section>
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    <table border="0">
      <tbody>
        <tr>
          <td>Entlassungbefund</td>          <td>Körpertemperatur 37.9°C, ø verstärkten Atemgeräusche, ø Tachypnoe</td>        </tr>      </tbody>    </table>  </text></section>
ItemDTKardKonfBeschreibungLabel
hl7:section
(BefundebeiEntlassung)
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1 .. 1F1.2.276.0.76.10.3060
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II0 .. 1(BefundebeiEntlassung)
Treetree.pnghl7:code
CE1 .. 1M(BefundebeiEntlassung)
Treeblank.pngTreetree.png@code
1 .. 1F11493-4
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Treeblank.pngTreetree.png@codeSystemName
1 .. 1FLOINC
Treetree.pnghl7:title
ST1 .. 1M(BefundebeiEntlassung)
 CONF
Elementinhalt muss "Zusammenfassung der Befunde bei Entlassung" sein
Treetree.pnghl7:text
SD.TEXT1 .. 1MTextfeld ist gemäß Beispiel zu strukturieren(BefundebeiEntlassung)
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