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Version vom 18. Juli 2019, 14:49 Uhr

  1. Document
     PflegerischerEntlassungsbericht (2.16.840.1.113883.3.1937.99.61.34.10.28)
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       CDA id (1.2.276.0.76.10.90004)
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       CDA effectiveTime (1.2.276.0.76.10.90006)
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       CDA confidentialityCode (1.2.276.0.76.10.90007)
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       CDA recordTarget (1.2.276.0.76.10.2001)
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         Personenname (1.2.276.0.76.10.90030)
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       CDA author (1.2.276.0.76.10.2002)
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         CDA Person Elements (1.2.276.0.76.10.90010)
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         CDA Organization Elements (1.2.276.0.76.10.90011)
    10. Header
       CDA dataEnterer (1.2.276.0.76.10.2017)
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         CDA Assigned Entity Elements (1.2.276.0.76.10.90012)
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           CDA Person Elements (1.2.276.0.76.10.90010)
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           CDA Organization Elements (1.2.276.0.76.10.90011)
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       CDA Informant (1.2.276.0.76.10.2018)
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         CDA Assigned Entity Elements (1.2.276.0.76.10.90012)
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           CDA Person Elements (1.2.276.0.76.10.90010)
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           CDA Organization Elements (1.2.276.0.76.10.90011)
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         RelatedEntity (Body) (1.2.276.0.76.10.90020)
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           CDA Person Elements (1.2.276.0.76.10.90010)
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       CDA custodian (1.2.276.0.76.10.2004)
    13. Header
       CDA informationRecipient (1.2.276.0.76.10.2005)
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         CDA Person Elements (1.2.276.0.76.10.90010)
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         CDA Organization Elements (1.2.276.0.76.10.90011)
    14. Header
       CDA legalAuthenticator (1.2.276.0.76.10.2020)
      1. Header
         CDA Assigned Entity Elements (1.2.276.0.76.10.90012)
        1. Header
           CDA Person Elements (1.2.276.0.76.10.90010)
        2. Header
           CDA Organization Elements (1.2.276.0.76.10.90011)
    15. Header
       CDA authenticator (1.2.276.0.76.10.2019)
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         CDA Assigned Entity Elements (1.2.276.0.76.10.90012)
        1. Header
           CDA Person Elements (1.2.276.0.76.10.90010)
        2. Header
           CDA Organization Elements (1.2.276.0.76.10.90011)
    16. Header
       CDA participant Angehörige (1.2.276.0.76.10.2021)
      1. Header
         CDA Person Elements (1.2.276.0.76.10.90010)
      2. Header
         CDA Organization Elements (1.2.276.0.76.10.90011)
    17. Header
       CDA participant Ansprechpartner (1.2.276.0.76.10.2025)
      1. Header
         CDA Person Elements (1.2.276.0.76.10.90010)
      2. Header
         CDA Organization Elements (1.2.276.0.76.10.90011)
    18. Header
       CDA participant Betreuungsorganisation (1.2.276.0.76.10.2026)
      1. Header
         CDA Organization Elements (1.2.276.0.76.10.90011)
    19. Header
       CDA participant Weitere Beteiligte (1.2.276.0.76.10.2024)
      1. Header
         CDA Person Elements (1.2.276.0.76.10.90010)
      2. Header
         CDA Organization Elements (1.2.276.0.76.10.90011)
    20. Header
       CDA participant Einweiser (1.2.276.0.76.10.2023)
      1. Header
         CDA Person Elements (1.2.276.0.76.10.90010)
      2. Header
         CDA Organization Elements (1.2.276.0.76.10.90011)
    21. Header
       CDA participant Hausarzt (1.2.276.0.76.10.2012)
      1. Header
         CDA Person Elements (1.2.276.0.76.10.90010)
      2. Header
         CDA Organization Elements (1.2.276.0.76.10.90011)
    22. Header
       CDA encompassingEncounter Patientenkontakt (1.2.276.0.76.10.2027)
      1. Header
         CDA Assigned Entity Elements (1.2.276.0.76.10.90012)
        1. Header
           CDA Person Elements (1.2.276.0.76.10.90010)
        2. Header
           CDA Organization Elements (1.2.276.0.76.10.90011)
      2. Header
         Encounter Location (1.2.276.0.76.10.90021)
    23. Section
       Anrede (1.2.276.0.76.10.3001)
    24. Section
       Pflegeprozess Section (1.2.276.0.76.10.3003)
      1. Section
         Pflegediagnose Section (1.2.276.0.76.10.3004)
        1. Entry
           Pflegediagnose - Entry (2.16.840.1.113883.3.1937.99.61.34.10.27)
        2. Entry
           Hilfsmittel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.38)
          1. notype
             Manufactured Product (2.16.840.1.113883.3.1937.99.61.34.10.40)
            1. Header
               CDA Organization Elements (1.2.276.0.76.10.90011)
            2. notype
               Manufactured Material (2.16.840.1.113883.3.1937.99.61.34.10.39)
          2. notype
             Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
        3. Section
           Pflegeintervention Section (1.2.276.0.76.10.3010)
          1. Entry
             Pflegeintervention - Entry (2.16.840.1.113883.3.1937.99.61.34.10.30)
            1. Header
               CDA effectiveTime (1.2.276.0.76.10.90006)
          2. Section
             Pflegeergebnis Section (1.2.276.0.76.10.3011)
            1. Entry
               Pflegeergebnis - Entry (2.16.840.1.113883.3.1937.99.61.34.10.31)
        4. Section
           Ätiologie Section (1.2.276.0.76.10.3007)
        5. Section
           Symptome Section (1.2.276.0.76.10.3008)
        6. Section
           Ressource Section (1.2.276.0.76.10.3009)
      2. Section
         Assessment Section_Pflegebericht (2.16.840.1.113883.3.1937.99.61.34.10.42)
        1. Entry
           Hilfsmittel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.38)
          1. notype
             Manufactured Product (2.16.840.1.113883.3.1937.99.61.34.10.40)
            1. Header
               CDA Organization Elements (1.2.276.0.76.10.90011)
            2. notype
               Manufactured Material (2.16.840.1.113883.3.1937.99.61.34.10.39)
          2. notype
             Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
        2. Section
           Pflegeziel Section (1.2.276.0.76.10.3006)
          1. Entry
             Pflegeziel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.32)
          2. Entry
             Hilfsmittel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.38)
            1. notype
               Manufactured Product (2.16.840.1.113883.3.1937.99.61.34.10.40)
              1. Header
                 CDA Organization Elements (1.2.276.0.76.10.90011)
              2. notype
                 Manufactured Material (2.16.840.1.113883.3.1937.99.61.34.10.39)
            2. notype
               Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
          3. Section
             Ressource Section (1.2.276.0.76.10.3009)
          4. Section
             Pflegeintervention Section (1.2.276.0.76.10.3010)
            1. Entry
               Pflegeintervention - Entry (2.16.840.1.113883.3.1937.99.61.34.10.30)
              1. Header
                 CDA effectiveTime (1.2.276.0.76.10.90006)
            2. Section
               Pflegeergebnis Section (1.2.276.0.76.10.3011)
              1. Entry
                 Pflegeergebnis - Entry (2.16.840.1.113883.3.1937.99.61.34.10.31)
        3. Section
           Pflegeintervention Section (1.2.276.0.76.10.3010)
          1. Entry
             Pflegeintervention - Entry (2.16.840.1.113883.3.1937.99.61.34.10.30)
            1. Header
               CDA effectiveTime (1.2.276.0.76.10.90006)
          2. Section
             Pflegeergebnis Section (1.2.276.0.76.10.3011)
            1. Entry
               Pflegeergebnis - Entry (2.16.840.1.113883.3.1937.99.61.34.10.31)
      3. Section
         Pflegeziel Section (1.2.276.0.76.10.3006)
        1. Entry
           Pflegeziel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.32)
        2. Entry
           Hilfsmittel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.38)
          1. notype
             Manufactured Product (2.16.840.1.113883.3.1937.99.61.34.10.40)
            1. Header
               CDA Organization Elements (1.2.276.0.76.10.90011)
            2. notype
               Manufactured Material (2.16.840.1.113883.3.1937.99.61.34.10.39)
          2. notype
             Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
        3. Section
           Ressource Section (1.2.276.0.76.10.3009)
        4. Section
           Pflegeintervention Section (1.2.276.0.76.10.3010)
          1. Entry
             Pflegeintervention - Entry (2.16.840.1.113883.3.1937.99.61.34.10.30)
            1. Header
               CDA effectiveTime (1.2.276.0.76.10.90006)
          2. Section
             Pflegeergebnis Section (1.2.276.0.76.10.3011)
            1. Entry
               Pflegeergebnis - Entry (2.16.840.1.113883.3.1937.99.61.34.10.31)
      4. Section
         Pflegeintervention Section (1.2.276.0.76.10.3010)
        1. Entry
           Pflegeintervention - Entry (2.16.840.1.113883.3.1937.99.61.34.10.30)
          1. Header
             CDA effectiveTime (1.2.276.0.76.10.90006)
        2. Section
           Pflegeergebnis Section (1.2.276.0.76.10.3011)
          1. Entry
             Pflegeergebnis - Entry (2.16.840.1.113883.3.1937.99.61.34.10.31)
    25. Section
       SocialInformation (2.16.840.1.113883.3.1937.99.61.34.10.8)
      1. Section
         Ausgeübter Beruf (2.16.840.1.113883.3.1937.99.61.34.10.2)
    26. Section
       HomeCareStatus (2.16.840.1.113883.3.1937.99.61.34.10.21)
      1. Section
         Barrierefreiheit (2.16.840.1.113883.3.1937.99.61.34.10.17)
        1. Section
           Zugang zur Wohnung (2.16.840.1.113883.3.1937.99.61.34.10.16)
        2. Section
           Barrierefreiheit in der Wohnung (2.16.840.1.113883.3.1937.99.61.34.10.15)
        3. Section
           Wohnraumanpassung (2.16.840.1.113883.3.1937.99.61.34.10.14)
          1. notype
             Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
        4. Section
           Wohnumfeldberatung (2.16.840.1.113883.3.1937.99.61.34.10.13)
      2. Section
         Wohnform - narrativ (2.16.840.1.113883.3.1937.99.61.34.10.18)
      3. Section
         Wohnform (2.16.840.1.113883.3.1937.99.61.34.10.19)
        1. Entry
           Wohnform - Entry (2.16.840.1.113883.3.1937.99.61.34.10.41)
      4. Section
         Hilfsmittel (2.16.840.1.113883.3.1937.99.61.34.10.20)
        1. Entry
           Hilfsmittel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.38)
          1. notype
             Manufactured Product (2.16.840.1.113883.3.1937.99.61.34.10.40)
            1. Header
               CDA Organization Elements (1.2.276.0.76.10.90011)
            2. notype
               Manufactured Material (2.16.840.1.113883.3.1937.99.61.34.10.39)
          2. notype
             Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
    27. Section
       Sozialrechtliche Informationen (2.16.840.1.113883.3.1937.99.61.34.10.26)
      1. Section
         Bestellung eines Betreuers (2.16.840.1.113883.3.1937.99.61.34.10.25)
        1. Entry
           Betreuer (2.16.840.1.113883.3.1937.99.61.34.10.34)
          1. Header
             CDA Organization Elements (1.2.276.0.76.10.90011)
        2. Entry
           Vormundschaftsgericht (2.16.840.1.113883.3.1937.99.61.34.10.33)
          1. Header
             CDA Organization Elements (1.2.276.0.76.10.90011)
      2. Section
         Hilfe nach SGB XII (2.16.840.1.113883.3.1937.99.61.34.10.24)
        1. Entry
           Hilfe zur Pflege nach SGB XII (L3) (2.16.840.1.113883.3.1937.99.61.34.10.35)
      3. Section
         Pflegegrad (2.16.840.1.113883.3.1937.99.61.34.10.9)
        1. Entry
           Pflegegrad (2.16.840.1.113883.3.1937.99.61.34.10.7)
          1. notype
             Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
      4. Section
         Verfügungen (2.16.840.1.113883.3.1937.99.61.34.10.22)
        1. Entry
           Verfügungen - Entry (2.16.840.1.113883.3.1937.99.61.34.10.36)
        2. Header
           CDA custodian (1.2.276.0.76.10.2004)
    28. Section
       Medizinische Informationen (2.16.840.1.113883.3.1937.99.61.34.10.4)
      1. Section
         Aufnahmediagnose (1.2.276.0.76.10.3026)
        1. Entry
           Diagnose Concern Act (1.2.276.0.76.10.4079)
          1. Entry
             Author (Body) (1.2.276.0.76.10.90025)
            1. Header
               CDA Person Elements (1.2.276.0.76.10.90010)
            2. Header
               CDA Organization Elements (1.2.276.0.76.10.90011)
          2. Entry
             Diagnose Observation (1.2.276.0.76.10.4080)
            1. Entry
               Lateralität (1.2.276.0.76.10.90026)
            2. Entry
               Diagnosesicherheit (1.2.276.0.76.10.90027)
            3. Entry
               Author (Body) (1.2.276.0.76.10.90025)
              1. Header
                 CDA Person Elements (1.2.276.0.76.10.90010)
              2. Header
                 CDA Organization Elements (1.2.276.0.76.10.90011)
            4. Entry
               Alter Beobachtung (1.2.276.0.76.10.4077)
            5. Entry
               Prognose Observation (1.2.276.0.76.10.4078)
            6. Entry
               Priorität Präferenz (1.2.276.0.76.10.4076)
              1. Entry
                 Author (Body) (1.2.276.0.76.10.90025)
                1. Header
                   CDA Person Elements (1.2.276.0.76.10.90010)
                2. Header
                   CDA Organization Elements (1.2.276.0.76.10.90011)
            7. Entry
               Manifestation Observation (1.2.276.0.76.10.4093)
            8. Entry
               Etiology Observation (1.2.276.0.76.10.4094)
          3. Entry
             Priorität Präferenz (1.2.276.0.76.10.4076)
            1. Entry
               Author (Body) (1.2.276.0.76.10.90025)
              1. Header
                 CDA Person Elements (1.2.276.0.76.10.90010)
              2. Header
                 CDA Organization Elements (1.2.276.0.76.10.90011)
      2. Section
         Entlassungsdiagnose (1.2.276.0.76.10.3027)
        1. Entry
           Diagnose Concern Act (1.2.276.0.76.10.4079)
          1. Entry
             Author (Body) (1.2.276.0.76.10.90025)
            1. Header
               CDA Person Elements (1.2.276.0.76.10.90010)
            2. Header
               CDA Organization Elements (1.2.276.0.76.10.90011)
          2. Entry
             Diagnose Observation (1.2.276.0.76.10.4080)
            1. Entry
               Lateralität (1.2.276.0.76.10.90026)
            2. Entry
               Diagnosesicherheit (1.2.276.0.76.10.90027)
            3. Entry
               Author (Body) (1.2.276.0.76.10.90025)
              1. Header
                 CDA Person Elements (1.2.276.0.76.10.90010)
              2. Header
                 CDA Organization Elements (1.2.276.0.76.10.90011)
            4. Entry
               Alter Beobachtung (1.2.276.0.76.10.4077)
            5. Entry
               Prognose Observation (1.2.276.0.76.10.4078)
            6. Entry
               Priorität Präferenz (1.2.276.0.76.10.4076)
              1. Entry
                 Author (Body) (1.2.276.0.76.10.90025)
                1. Header
                   CDA Person Elements (1.2.276.0.76.10.90010)
                2. Header
                   CDA Organization Elements (1.2.276.0.76.10.90011)
            7. Entry
               Manifestation Observation (1.2.276.0.76.10.4093)
            8. Entry
               Etiology Observation (1.2.276.0.76.10.4094)
          3. Entry
             Priorität Präferenz (1.2.276.0.76.10.4076)
            1. Entry
               Author (Body) (1.2.276.0.76.10.90025)
              1. Header
                 CDA Person Elements (1.2.276.0.76.10.90010)
              2. Header
                 CDA Organization Elements (1.2.276.0.76.10.90011)
      3. Section
         Medikation bei Einweisung (Historie) (1.2.276.0.76.10.3029)
        1. Entry
           Medikation (1.2.276.0.76.10.4022)
          1. Entry
             Author (Body) (1.2.276.0.76.10.90025)
            1. Header
               CDA Person Elements (1.2.276.0.76.10.90010)
            2. Header
               CDA Organization Elements (1.2.276.0.76.10.90011)
          2. Entry
             RelatedEntity (Body) (1.2.276.0.76.10.90020)
            1. Header
               CDA Person Elements (1.2.276.0.76.10.90010)
          3. Entry
             Einzeldosierungen (1.2.276.0.76.10.4023)
          4. Entry
             Dosierung Freitext (1.2.276.0.76.10.4024)
      4. Section
         Medikation bei Entlassung (1.2.276.0.76.10.3031)
        1. Entry
           Medikation (1.2.276.0.76.10.4022)
          1. Entry
             Author (Body) (1.2.276.0.76.10.90025)
            1. Header
               CDA Person Elements (1.2.276.0.76.10.90010)
            2. Header
               CDA Organization Elements (1.2.276.0.76.10.90011)
          2. Entry
             RelatedEntity (Body) (1.2.276.0.76.10.90020)
            1. Header
               CDA Person Elements (1.2.276.0.76.10.90010)
          3. Entry
             Einzeldosierungen (1.2.276.0.76.10.4023)
          4. Entry
             Dosierung Freitext (1.2.276.0.76.10.4024)
      5. Section
         Verabreichte Medikation während des Aufenthalts (1.2.276.0.76.10.3030)
        1. Entry
           Medikation (1.2.276.0.76.10.4022)
          1. Entry
             Author (Body) (1.2.276.0.76.10.90025)
            1. Header
               CDA Person Elements (1.2.276.0.76.10.90010)
            2. Header
               CDA Organization Elements (1.2.276.0.76.10.90011)
          2. Entry
             RelatedEntity (Body) (1.2.276.0.76.10.90020)
            1. Header
               CDA Person Elements (1.2.276.0.76.10.90010)
          3. Entry
             Einzeldosierungen (1.2.276.0.76.10.4023)
          4. Entry
             Dosierung Freitext (1.2.276.0.76.10.4024)
    29. Section
       Abschließende Bemerkungen (1.2.276.0.76.10.3034)
    30. Section
       Beilagen/Anhang (1.2.276.0.76.10.3037)
      1. Entry
         Eingebettetes Objekt Entry (1.2.276.0.76.10.4014)
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