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

Version vom 22. August 2018, 02:52 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 4 Konzepte

Id	Name	Datensatz
dguvbbr-dataelement2-112	Diagnose/Problem	Stationärer Entlassungsbericht
dguvbbr-dataelement2-113	Jargondiagnose/Freitext	Stationärer Entlassungsbericht
dguvbbr-dataelement2-114	Code	Stationärer Entlassungsbericht
dguvbbr-dataelement2-115	Anzeigename	Stationärer Entlassungsbericht

Benutzt

Benutzt 2 Templates

Benutzt	als	Name	Version
1.2.276.0.76.10.90026	Inklusion	Lateralität	DYNAMIC
1.2.276.0.76.10.90027	Inklusion	Diagnosesicherheit	DYNAMIC

Beziehung Version: Template 1.2.276.0.76.10.4080 (2015‑12‑06)
Spezialisierung: Template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Adaptation: Template 2.16.840.1.113883.10.20.22.4.4 (2015‑08‑01)
Spezialisierung: Template 1.2.276.0.76.10.4075 (2015‑12‑06)

Beispiel

Beispiel Hauptdiagnose mit ICD 10 GM 2016: Distale Fraktur des Radius links, Extensionsfraktur

Beispiel

Beispiel Nebendiagnose mit ICD 10 GM 2016: Weichteilschaden I. Grades bei geschlossener Fraktur oder Luxation des Unterarmes, gesichert

Beispiel

Beispiel Nebendiagnose mit ICD 10 GM 2016: Diabetes mellitus, Typ 2 : Mit multiplen Komplikationen, gesichert

Item DT Kard Konf Beschreibung Label

hl7:observation

(Dia...on2)


	dguvbbr-dataelement2-112	Diagnose/Problem	Stationärer Entlassungsbericht

@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)

CONF

@code muss "52534-5" sein

@codeSystem muss "2.16.840.1.113883.6.1" sein

@displayName muss "Principal Diagnosis" sein

oder

@code muss "81885-6" sein

@codeSystem muss "2.16.840.1.113883.6.1" sein

@displayName muss "Secondary Diagnosis" sein

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

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

CONF

muss aus der Konzeptdomäne "Diagnosecodes (ICD-10)" gewählt werden

hl7:qualifier

CR

0 … *

(Dia...on2)

Eingefügt von 1.2.276.0.76.10.90026 Lateralität (DYNAMIC)

hl7:qualifier

CR

0 … 1

Seitenlokalisation

(Dia...on2)

wo [hl7:name/@code='20228-3']


	dguvbbr-dataelement2-254	Seitigkeit	Stationärer Entlassungsbericht

Beispiel <qualifier> <name code="20228-3" codeSystem="2.16.840.1.113883.6.1"/> <value code="L" codeSystem="1.2.276.0.76.5.412"/></qualifier>

hl7:name

CV

1 … 1

M

(Dia...on2)

@code

CONF

1 … 1

F

20228-3

@codeSystem

1 … 1

F

2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)

hl7:value

CV

1 … 1

R

(Dia...on2)


dguvbbr-dataelement1-54	Seitigkeit	Mini-Entlassbrief
dguvbbr-dataelement1-55	Seitigkeit	Mini-Entlassbrief

CONF

Der Wert von @code muss gewählt werden aus dem Value Set 1.2.276.0.76.11.412 Lateralität (DYNAMIC)

Eingefügt von 1.2.276.0.76.10.90027 Diagnosesicherheit (DYNAMIC)

hl7:qualifier

CR

0 … 1

Optionale Angabe der Diagnosesicherheit (laut §295 SGB V) als Qualifier-Kind-Element des value-Elements des Problems (Diagnose).

(Dia...on2)

wo [hl7:name/@code='8']


	dguvbbr-dataelement2-253	Diagnosensicherheit	Stationärer Entlassungsbericht

Beispiel <qualifier> <name code="8" codeSystem="2.16.840.1.113883.3.7.1.0"/> <value code="G" codeSystem="1.2.276.0.76.3.1.1.5.1.21"/></qualifier>

hl7:name

CV

1 … 1

M

(Dia...on2)

@code

CONF

1 … 1

F

8

@codeSystem

1 … 1

F

2.16.840.1.113883.3.7.1.0

hl7:value

CV

1 … 1

M

(Dia...on2)


dguvbbr-dataelement1-56	Diagnosesicherheit	Mini-Entlassbrief
dguvbbr-dataelement1-53	Diagnosensicherheit	Mini-Entlassbrief

CONF

Der Wert von @code muss gewählt werden aus dem Value Set 1.2.276.0.76.11.121 S_ICD_DIAGNOSESICHERHEIT (DYNAMIC)

hl7:translation

0 … *

(Dia...on2)

@code

0 … 1

hl7:originalText

ED

0 … 1

C

(Dia...on2)


	dguvbbr-dataelement2-113	Jargondiagnose/Freitext	Stationärer Entlassungsbericht

Beispiel <hl7:originalText/>

Variable let Name sgbv295q

Value hl7:value/hl7:qualifier[hl7:name/@codeSystem='2.16.840.1.113883.3.7.1.0']/hl7:value/@code

Schematron assert role error

test not($sgbv295q='G') or hl7:participant[@typeCode='AUTHEN']

Meldung Wenn Zusatzkennzeichen 'G' nach §295 SGB V angegeben wird, muss ein participant mit @typeCode='AUTHEN' vorhanden sein.

Schematron assert role error

test not($sgbv295q='A') or @negationInd='true'

Meldung Wenn Zusatzkennzeichen 'A' nach §295 SGB V angegeben wird, muss bei der Observation @negationInd='true' angegeben sein.

Schematron assert role error

test not($sgbv295q='Z') or hl7:effectiveTime/hl7:high

Meldung Wenn Zusatzkennzeichen 'Z' nach §295 SGB V angegeben wird, muss bei der Observation effectiveTime.high angegeben sein.

Version vom 14. August 2018, 02:52 Uhr (Quelltext anzeigen) ADbot (Diskussion \| Beiträge) (Automated ADBot page content) ← Zum vorherigen Versionsunterschied		Version vom 22. August 2018, 02:52 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~~<div>Andere Versionen mit dieser Id:<ul></ul></div>~~</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 4 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%;"><span style="color: grey;">dguvbbr-dataelement2-</span>112</td><td style="vertical-align: top;" title="Diagnosen/Probleme / ">[[File:Kyellow.png\|14px]] Diagnose/Problem </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%;"><span style="color: grey;">dguvbbr-dataelement2-</span>113</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem / ">[[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%;"><span style="color: grey;">dguvbbr-dataelement2-</span>114</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem / ">[[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%;"><span style="color: grey;">dguvbbr-dataelement2-</span>115</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem / ">[[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 2 Templates</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;">1.2.276.0.76.10.90026</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kyellow.png\|14px]] Lateralität</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.276.0.76.10.90027</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kyellow.png\|14px]] Diagnosesicherheit</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> </i> (2015‑12‑06)<br />Spezialisierung: Template 2.16.840.1.113883.10.12.303 <i> </i> (2005‑09‑07)<br />Adaptation: Template 2.16.840.1.113883.10.20.22.4.4 <i> </i> (2015‑08‑01)<br />Spezialisierung: Template 1.2.276.0.76.10.4075 <i> </i> (2015‑12‑06)</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 Hauptdiagnose mit ICD 10 GM 2016: Distale Fraktur des Radius links, Extensionsfraktur</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</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;"> <span style="color:green"><!-- Diagnose Observation --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.4080</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">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">451791b0-5c71-11db-b0de-0800200c9a66</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">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">52534-5</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="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Principal Diagnosis</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">text</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#hauptdiag-1</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">text</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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="ppelement">effectiveTime</span><span class="ppsign">></span><br /><span style="display: block;"> <span style="color:green"><!-- Das low Element gibt das Datum an, seit wann der Patient diese Diagnose hat --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">201802280810</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">effectiveTime</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">S52.51</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.430</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Distale Fraktur des Radius, Extensionsfraktur</span><span class="ppsign">"</span><span class="ppsign">></span><br /><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">20228-3</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="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">L</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.412</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> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">value</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">></span></span></tt></td></tr></table></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 Nebendiagnose mit ICD 10 GM 2016: Weichteilschaden I. Grades bei geschlossener Fraktur oder Luxation des Unterarmes, gesichert</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</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;"> <span style="color:green"><!-- Diagnose Observation --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.4080</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">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">765791b0-5c71-11db-b0de-0800200c9a66</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">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">81885-6</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="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Secondary Diagnosis</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">text</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#nebendiag-1</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">text</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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="ppelement">effectiveTime</span><span class="ppsign">></span><br /><span style="display: block;"> <span style="color:green"><!-- Das low Element gibt das Datum an, seit wann der Patient diese Diagnose hat --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">201802280810</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">effectiveTime</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">S51.84</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.430</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Weichteilschaden I. Grades bei geschlossener Fraktur oder Luxation des Unterarmes</span><span class="ppsign">"</span><span class="ppsign">></span><br /><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">20228-3</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="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">L</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.412</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><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">8</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.3.7.1.0</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">G</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.3.1.1.5.1.21</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> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">value</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">></span></span></tt></td></tr></table></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 Nebendiagnose mit ICD 10 GM 2016: Diabetes mellitus, Typ 2 : Mit multiplen Komplikationen, gesichert</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</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;"> <span style="color:green"><!-- Diagnose Observation --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.4080</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">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">765791b0-5c71-11db-b0de-0800200c9a66</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">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">81885-6</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="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Secondary Diagnosis</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">text</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#nebendiag-2</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">text</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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="ppelement">effectiveTime</span><span class="ppsign">></span><br /><span style="display: block;"> <span style="color:green"><!-- Das low Element gibt das Datum an, seit wann der Patient diese Diagnose hat --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">201802280810</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">effectiveTime</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">E11.72</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.430</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Diabetes mellitus, Typ 2 : Mit multiplen Komplikationen</span><span class="ppsign">"</span><span class="ppsign">></span><br /><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">8</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.3.7.1.0</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">G</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.3.1.1.5.1.21</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> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">value</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></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 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;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement2-</span>112</td><td style="vertical-align: top;" title="Diagnosen/Probleme / ">[[File:Kyellow.png\|14px]] Diagnose/Problem </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png\|14px]] Stationärer Entlassungsbericht </td></tr></table></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 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>@code muss "52534-5" sein</td></tr><tr style="vertical-align: top;"><td>@codeSystem muss "2.16.840.1.113883.6.1" sein</td></tr><tr style="vertical-align: top;"><td>@displayName muss "Principal Diagnosis" sein</td></tr><tr style="vertical-align: top;"><td>oder</td></tr><tr style="vertical-align: top;"><td>@code muss "81885-6" sein</td></tr><tr style="vertical-align: top;"><td>@codeSystem muss "2.16.840.1.113883.6.1" sein</td></tr><tr style="vertical-align: top;"><td>@displayName muss "Secondary Diagnosis" sein</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: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>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;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement2-</span>114</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem / ">[[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;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement2-</span>115</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem / ">[[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;"><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>muss aus der Konzeptdomäne "Diagnosecodes (ICD-10)" gewählt werden</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:qualifier<br /></strong></tt></td></tr></table></td><td><strong>CR</strong></td><td><span style="color: black;"><strong>0 … </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 class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td colspan="2"> von 1.2.276.0.76.10.90026 <i>Lateralität</i> (DYNAMIC)</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>Seitenlokalisation</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='20228-3']</i></td></tr></table></td><td></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;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement2-</span>254</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem / ">[[File:Kyellow.png\|14px]] Seitigkeit </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="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">20228-3</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="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">L</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.412</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">20228-3</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">2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)</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>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;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement1-</span>54</td><td style="vertical-align: top;" title="Diagnosen / Hauptdiagnose / ">[[File:Kyellow.png\|14px]] Seitigkeit </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png\|14px]] Mini-Entlassbrief </td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement1-</span>55</td><td style="vertical-align: top;" title="Diagnosen / Nebendiagnose / ">[[File:Kyellow.png\|14px]] Seitigkeit </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png\|14px]] Mini-Entlassbrief </td></tr></table></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 1.2.276.0.76.11.412 <i>Lateralität </i>(DYNAMIC)</td></tr></table></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td colspan="2"> von 1.2.276.0.76.10.90027 <i>Diagnosesicherheit</i> (DYNAMIC)</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>Optionale Angabe der Diagnosesicherheit (laut §295 SGB V) als Qualifier-Kind-Element des value-Elements des Problems (Diagnose).</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='8']</i></td></tr></table></td><td></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;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement2-</span>253</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem / ">[[File:Kyellow.png\|14px]] Diagnosensicherheit </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="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">8</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.3.7.1.0</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">G</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.3.1.1.5.1.21</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">8</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">2.16.840.1.113883.3.7.1.0</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;"> </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;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement1-</span>56</td><td style="vertical-align: top;" title="Diagnosen / Nebendiagnose / ">[[File:Kyellow.png\|14px]] Diagnosesicherheit </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png\|14px]] Mini-Entlassbrief </td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement1-</span>53</td><td style="vertical-align: top;" title="Diagnosen / Hauptdiagnose / ">[[File:Kyellow.png\|14px]] Diagnosensicherheit </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png\|14px]] Mini-Entlassbrief </td></tr></table></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 1.2.276.0.76.11.121 <i>S_ICD_DIAGNOSESICHERHEIT </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:Treeblank.png\|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>hl7:translation<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></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>@code<br /></strong></tt></td></tr></table></td><td></td><td><span><strong>0 … 1</strong></span></td><td> </td><td style="vertical-align: top;" colspan="2"></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;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement2-</span>113</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem / ">[[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="ppsign">></span></span></tt></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="2" class="defvar">Variable let</td><td style="background-color: #FFEEEE;">Name</td><td colspan="2">sgbv295q</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Value</td><td colspan="2">hl7:value/hl7:qualifier[hl7:name/@codeSystem='2.16.840.1.113883.3.7.1.0']/hl7:value/@code</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2">[[File:Kred.png\|14px]] error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">not($sgbv295q='G') or hl7:participant[@typeCode='AUTHEN']</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">Wenn Zusatzkennzeichen 'G' nach §295 SGB V angegeben wird, muss ein participant mit @typeCode='AUTHEN' vorhanden sein.</span></td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2">[[File:Kred.png\|14px]] error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">not($sgbv295q='A') or @negationInd='true'</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">Wenn Zusatzkennzeichen 'A' nach §295 SGB V angegeben wird, muss bei der Observation @negationInd='true' angegeben sein.</span></td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2">[[File:Kred.png\|14px]] error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">not($sgbv295q='Z') or hl7:effectiveTime/hl7:high</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">Wenn Zusatzkennzeichen 'Z' nach §295 SGB V angegeben wird, muss bei der Observation effectiveTime.high angegeben sein.</span></td><td style="background-color: white;"> </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 4 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%;"><span style="color: grey;">dguvbbr-dataelement2-</span>112</td><td style="vertical-align: top;" title="Diagnosen/Probleme / ">[[File:Kyellow.png\|14px]] Diagnose/Problem </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%;"><span style="color: grey;">dguvbbr-dataelement2-</span>113</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem / ">[[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%;"><span style="color: grey;">dguvbbr-dataelement2-</span>114</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem / ">[[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%;"><span style="color: grey;">dguvbbr-dataelement2-</span>115</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem / ">[[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 2 Templates</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;">1.2.276.0.76.10.90026</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kyellow.png\|14px]] Lateralität</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.276.0.76.10.90027</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kyellow.png\|14px]] Diagnosesicherheit</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> </i> (2015‑12‑06)<br />Spezialisierung: Template 2.16.840.1.113883.10.12.303 <i> </i> (2005‑09‑07)<br />Adaptation: Template 2.16.840.1.113883.10.20.22.4.4 <i> </i> (2015‑08‑01)<br />Spezialisierung: Template 1.2.276.0.76.10.4075 <i> </i> (2015‑12‑06)</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 Hauptdiagnose mit ICD 10 GM 2016: Distale Fraktur des Radius links, Extensionsfraktur</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</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;"> <span style="color:green"><!-- Diagnose Observation --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.4080</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">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">451791b0-5c71-11db-b0de-0800200c9a66</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">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">52534-5</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="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Principal Diagnosis</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">text</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#hauptdiag-1</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">text</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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="ppelement">effectiveTime</span><span class="ppsign">></span><br /><span style="display: block;"> <span style="color:green"><!-- Das low Element gibt das Datum an, seit wann der Patient diese Diagnose hat --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">201802280810</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">effectiveTime</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">S52.51</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.430</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Distale Fraktur des Radius, Extensionsfraktur</span><span class="ppsign">"</span><span class="ppsign">></span><br /><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">20228-3</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="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">L</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.412</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> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">value</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">></span></span></tt></td></tr></table></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 Nebendiagnose mit ICD 10 GM 2016: Weichteilschaden I. Grades bei geschlossener Fraktur oder Luxation des Unterarmes, gesichert</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</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;"> <span style="color:green"><!-- Diagnose Observation --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.4080</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">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">765791b0-5c71-11db-b0de-0800200c9a66</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">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">81885-6</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="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Secondary Diagnosis</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">text</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#nebendiag-1</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">text</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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="ppelement">effectiveTime</span><span class="ppsign">></span><br /><span style="display: block;"> <span style="color:green"><!-- Das low Element gibt das Datum an, seit wann der Patient diese Diagnose hat --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">201802280810</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">effectiveTime</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">S51.84</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.430</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Weichteilschaden I. Grades bei geschlossener Fraktur oder Luxation des Unterarmes</span><span class="ppsign">"</span><span class="ppsign">></span><br /><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">20228-3</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="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">L</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.412</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><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">8</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.3.7.1.0</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">G</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.3.1.1.5.1.21</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> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">value</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">observation</span><span class="ppsign">></span></span></tt></td></tr></table></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 Nebendiagnose mit ICD 10 GM 2016: Diabetes mellitus, Typ 2 : Mit multiplen Komplikationen, gesichert</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</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;"> <span style="color:green"><!-- Diagnose Observation --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.4080</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">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">765791b0-5c71-11db-b0de-0800200c9a66</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">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">81885-6</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="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Secondary Diagnosis</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">text</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">reference</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">#nebendiag-2</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">text</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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="ppelement">effectiveTime</span><span class="ppsign">></span><br /><span style="display: block;"> <span style="color:green"><!-- Das low Element gibt das Datum an, seit wann der Patient diese Diagnose hat --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">201802280810</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">effectiveTime</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</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="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">E11.72</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.430</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Diabetes mellitus, Typ 2 : Mit multiplen Komplikationen</span><span class="ppsign">"</span><span class="ppsign">></span><br /><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">8</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.3.7.1.0</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">G</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.3.1.1.5.1.21</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> <span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">value</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></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 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;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement2-</span>112</td><td style="vertical-align: top;" title="Diagnosen/Probleme / ">[[File:Kyellow.png\|14px]] Diagnose/Problem </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png\|14px]] Stationärer Entlassungsbericht </td></tr></table></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 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>@code muss "52534-5" sein</td></tr><tr style="vertical-align: top;"><td>@codeSystem muss "2.16.840.1.113883.6.1" sein</td></tr><tr style="vertical-align: top;"><td>@displayName muss "Principal Diagnosis" sein</td></tr><tr style="vertical-align: top;"><td>oder</td></tr><tr style="vertical-align: top;"><td>@code muss "81885-6" sein</td></tr><tr style="vertical-align: top;"><td>@codeSystem muss "2.16.840.1.113883.6.1" sein</td></tr><tr style="vertical-align: top;"><td>@displayName muss "Secondary Diagnosis" sein</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: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>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;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement2-</span>114</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem / ">[[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;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement2-</span>115</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem / ">[[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;"><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>muss aus der Konzeptdomäne "Diagnosecodes (ICD-10)" gewählt werden</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:qualifier<br /></strong></tt></td></tr></table></td><td><strong>CR</strong></td><td><span style="color: black;"><strong>0 … </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 class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td colspan="2"> von 1.2.276.0.76.10.90026 <i>Lateralität</i> (DYNAMIC)</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>Seitenlokalisation</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='20228-3']</i></td></tr></table></td><td></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;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement2-</span>254</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem / ">[[File:Kyellow.png\|14px]] Seitigkeit </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="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">20228-3</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="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">L</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.412</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">20228-3</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">2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)</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>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;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement1-</span>54</td><td style="vertical-align: top;" title="Diagnosen / Hauptdiagnose / ">[[File:Kyellow.png\|14px]] Seitigkeit </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png\|14px]] Mini-Entlassbrief </td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement1-</span>55</td><td style="vertical-align: top;" title="Diagnosen / Nebendiagnose / ">[[File:Kyellow.png\|14px]] Seitigkeit </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png\|14px]] Mini-Entlassbrief </td></tr></table></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 1.2.276.0.76.11.412 <i>Lateralität </i>(DYNAMIC)</td></tr></table></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;;"><strong></strong></span></td><td colspan="2"> von 1.2.276.0.76.10.90027 <i>Diagnosesicherheit</i> (DYNAMIC)</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>Optionale Angabe der Diagnosesicherheit (laut §295 SGB V) als Qualifier-Kind-Element des value-Elements des Problems (Diagnose).</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='8']</i></td></tr></table></td><td></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;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement2-</span>253</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem / ">[[File:Kyellow.png\|14px]] Diagnosensicherheit </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="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">8</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.3.7.1.0</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">G</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.3.1.1.5.1.21</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">8</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">2.16.840.1.113883.3.7.1.0</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;"> </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;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement1-</span>56</td><td style="vertical-align: top;" title="Diagnosen / Nebendiagnose / ">[[File:Kyellow.png\|14px]] Diagnosesicherheit </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png\|14px]] Mini-Entlassbrief </td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement1-</span>53</td><td style="vertical-align: top;" title="Diagnosen / Hauptdiagnose / ">[[File:Kyellow.png\|14px]] Diagnosensicherheit </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png\|14px]] Mini-Entlassbrief </td></tr></table></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 1.2.276.0.76.11.121 <i>S_ICD_DIAGNOSESICHERHEIT </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:Treeblank.png\|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png\|16px]]</td><td><tt><strong>hl7:translation<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></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>@code<br /></strong></tt></td></tr></table></td><td></td><td><span><strong>0 … 1</strong></span></td><td> </td><td style="vertical-align: top;" colspan="2"></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;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-dataelement2-</span>113</td><td style="vertical-align: top;" title="Diagnosen/Probleme / Diagnose/Problem / ">[[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="ppsign">></span></span></tt></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="2" class="defvar">Variable let</td><td style="background-color: #FFEEEE;">Name</td><td colspan="2">sgbv295q</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Value</td><td colspan="2">hl7:value/hl7:qualifier[hl7:name/@codeSystem='2.16.840.1.113883.3.7.1.0']/hl7:value/@code</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2">[[File:Kred.png\|14px]] error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">not($sgbv295q='G') or hl7:participant[@typeCode='AUTHEN']</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">Wenn Zusatzkennzeichen 'G' nach §295 SGB V angegeben wird, muss ein participant mit @typeCode='AUTHEN' vorhanden sein.</span></td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2">[[File:Kred.png\|14px]] error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">not($sgbv295q='A') or @negationInd='true'</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">Wenn Zusatzkennzeichen 'A' nach §295 SGB V angegeben wird, muss bei der Observation @negationInd='true' angegeben sein.</span></td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2">[[File:Kred.png\|14px]] error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">not($sgbv295q='Z') or hl7:effectiveTime/hl7:high</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">Wenn Zusatzkennzeichen 'Z' nach §295 SGB V angegeben wird, muss bei der Observation effectiveTime.high angegeben sein.</span></td><td style="background-color: white;"> </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

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