2.16.840.1.113883.3.1937.777.35.10.68/static-2019-05-24T225802: Unterschied zwischen den Versionen
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− | <table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">2.16.840.1.113883.3.1937.777.35.10.68</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2019‑05‑24 22:58:02</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;">ElektronischerImpfpassDiagnosis</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Diagnose (cdaab2)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beschreibung</th><td style="text-align: left;" colspan="3">Bildet eine Diagnose ab. Die Informationen hierzu stammen aus folgender Quelle: http://wiki.hl7.de/index.php?title=cdaab2:ICD-Diagnose_Entry_(Template)</td></tr><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 2.16.840.1.113883.3.1937.777.35.10.68</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 1 Konzept</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%;">eImpfpass-data​element-147</td><td style="vertical-align: top;" title="Elektronischer Impfpass / Diagnosen und Symptome / ">[[File:Kyellow.png|14px]] Datum </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Impfpass </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 3 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;">1.2.276.0.76.10.2029</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] CDA author (pmp)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">2.16.840.1.113883.10.12.321</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] CDA Participant (Body)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">2.16.840.1.113883.3.1937.777.35.10.69</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Diagnose Ausnahmebegründung</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">Spezialisierung: Template 2.16.840.1.113883.10.12.303 <i>CDA Observation </i> (2005‑09‑07) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">ad1bbr-</div></span></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</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppnamespace">hl7:</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="ppattribute">negationInd</span><span class="ppsign">="</span><span class="ppcontent">false</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.3.1937.777.35.10.68</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="ppnamespace">hl7:</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.3.999</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">--example only--</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="ppnamespace">hl7:</span><span class="ppelement">code</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.3.1937.777.35.11.17</span><span class="ppsign">"</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">DIA</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="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">></span><span class="pptext">text</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">true</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="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20190621112754</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</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">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.413</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">qualifier</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</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="ppnamespace">hl7:</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">1.2.276.0.76.11.121</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Gesichert</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">qualifier</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">targetSiteCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">R</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.11.412</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Rechts</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="ppnamespace">hl7:</span><span class="ppelement">author</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.2029</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Diagnosedatum 1..1 M --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">time</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20131020</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="ppnamespace">hl7:</span><span class="ppelement">assignedAuthor</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">id</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">720091905</span><span class="ppsign">"</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.4.16</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">assignedAuthor</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">author</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">participant</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">ENT</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.10.12.321</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Dokumentationsdatum 1..1 R--><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">time</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20131020</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="ppnamespace">hl7:</span><span class="ppelement">participantRole</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">participant</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Ausnhamebegündung 0..1 --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">RSON</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</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;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.3.1937.777.35.10.69</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="ppnamespace">hl7:</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="ppnamespace">hl7:</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">ST</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">value</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">entryRelationship</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace">hl7:</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="">(Ele...sis)</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: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><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>@negationInd<br /></strong></tt></td></tr></table></td><td>bl</td><td><span><strong>0 … 1</strong></span></td><td> </td><td style="vertical-align: top;" colspan="2">Das Attribut @negationInd ist vom Datentyp BL und hat damit die Ausprägungen "true" oder "false". Wird das Attribut mit „true" angegeben, so wird ausgesagt, dass die über die Observation-Klasse beschriebene Beobachtung negiert wird. In Bezug auf die Diagnosendarstellung bedeutet das, dass die beschriebene Diagnose nicht zutrifft. Die Angabe des Attributs ist optional. Wird es nicht angegeben, geht das empfangende System von dem Default-Wert aus und verwendet diesen zur weiteren Verarbeitung. Der Default–Wert ist „false".<br /></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>II</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="">(Ele...sis)</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">2.16.840.1.113883.3.1937.777.35.10.68</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>II</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>Über das Attribut id kann die Diagnose eine eindeutige Identifikation innerhalb eines Systems erhalten. Für die Verarbeitung von Diagnosedaten über ein rechnergestütztes System ist die Vergabe von Ids empfehlenswert, um gezielt auf den Datensatz der Diagnose zugreifen zu können. In der XML-Repräsentation wird die Diagnose-ID im Attribut @extension und die OID des Systems im Attribut @root angegeben. Sollen für Diagnosen später Änderungen oder Löschungen kommuniziert werden, ist eine eindeutige Referenzierung über diese Identifikation unerlässlich.</td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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>CD</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="">(Ele...sis)</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>@codeSystem<br /></strong></tt></td></tr></table></td><td>oid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">2.16.840.1.113883.3.1937.777.35.11.17</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>@code<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">DIA</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>ST</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Der erläuternde Text zu einer Diagnose wird über das Attribut @text abgebildet. Die strukturierte Darstellung sieht wie folgt aus.</td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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:statusCode<br /></strong></tt></td></tr></table></td><td><strong>CS</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>Über dieses Attribut wird der Status, in dem der beschriebene Act sich befindet, angegeben. Ein Act kann z.B. den Status „new", „active" oder „cancelled" besitzen. Die Beobachtung einer Diagnose wird mit der Dokumentation als abgeschlossene Handlung betrachtet. Somit wird für das Attribut statusCode der feste Wert „completed" vorgegeben.<br /></td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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>@code<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">true</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>IVL_TS</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 Attribute <i>effectiveTime</i> der Klasse <i>Observation</i> gibt den Zeitraum an, für den die beschriebene Beobachtung für den Patienten gültig (klinisch relevant) ist bzw. war. In Bezug auf die Darstellung einer Diagnose, handelt es sich um den Diagnosezeitraum, der über das Element <i>effectiveTime</i> abgebildet wird. Über das Unterelement <i>low</i> wird das Startdatum des Zeitraums angegeben, über das Unterelement <i>high</i> das Enddatum. Sowohl das Element <i>low</i> als auch das Element <i>high</i> können alleine angegeben werden</td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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;">eImpfpass-data​element-147</td><td style="vertical-align: top;" title="Elektronischer Impfpass / Diagnosen und Symptome / ">[[File:Kyellow.png|14px]] Datum </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Impfpass </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: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>M</strong></span></td><td>Die Darstellung eines Diagnosecodes und des zum Code gehörenden Text erfolgt über das Attribut <i>value</i> der Klasse <i>Observation</i>. Das XML-Attribut <i>@code</i> des Elements <i>value </i>enthält<i> </i>den Diagnosecode, das XML-Attribut <i>@displayName</i> enthält den zum Code gehörenden Text. Die strukturierte Darstellung für eine ICD-10 codierte Diagnose sieht wie folgt aus. </td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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>@codeSystem<br /></strong></tt></td></tr></table></td><td>oid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.276.0.76.5.413</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"><div>Default</div><tt><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">I01.0</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Akute rheumatische Perikarditis</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.413</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">originalText</span><span class="ppsign">></span><span class="pptext">......</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">originalText</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!--Diagnosesicherheit--><br /></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">2.16.840.1.113883.3.7.1.8</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></tt></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"><div>Freitext</div><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">value</span> <span class="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">NAV</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">originalText</span><span class="ppsign">></span><span class="pptext">Rektumkarzinom mit Höhenlokalisation ab Anokutanlinie/Linea dentata</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">originalText</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">value</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: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>R</strong></span></td><td>Die Angabe der Diagnosesicherheit wird über dieses Kindelement <i>qualifier</i> abgebildet. <br />Wenn Diagnosesicherheit "A" angegeben, muss <i>negationInd=true </i>gesetzt werden.<br />Wenn Diagnosesicherheit "V" angegeben, muss <i>Author.typeCode="AUTH" </i>gesetzt sein.<br /></td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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: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="">(Ele...sis)</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>CD</strong> (erforderlich)</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="">(Ele...sis)</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>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: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:originalText<br /></strong></tt></td></tr></table></td><td><strong>ST</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="">(Ele...sis)</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:target​Site​Code<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>Die Lokalisation zu Diagnosen wird über das Element targetSiteCode angegeben. Wird die Lokalisation im Freitext angegeben, erfolgt die Darstellung über das Unterelement orginalText. Bei fehlender Codierung muss im Element targetSiteCode das Attribut @nullFlavor angegeben werden.</td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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>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="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Beispiel</td><td colspan="4" class="explabelblue"><div>Default</div><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">targetSiteCode</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">2.16.840.1.113883.3.1937.777.35.11.18</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span></tt></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"><div>Freitext-Angabe</div><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">targetSiteCode</span> <span class="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">NI</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">originalText</span><span class="ppsign">></span><span class="pptext">Oberhalb des rechten Knöchels</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">originalText</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">targetSiteCode</span><span class="ppsign">></span></span></tt></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"><div>Systemerkrankung (bzw. im Sinne von „nicht zutreffend")</div><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">targetSiteCode</span> <span class="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">NA</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span></tt></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"><div>Unbekannt</div><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">targetSiteCode</span> <span class="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">UNK</span><span class="ppsign">"</span><span class="ppsign">/</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:Treetree.png|16px]]</td><td><tt><strong>hl7:originalText<br /></strong></tt></td></tr></table></td><td><strong>ST</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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:author<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>Das Diagnosedatum wird über die Klasse <i>author</i> dargestellt, welche als <i>Participation</i> mit der Klasse <i>Observation</i> verbunden ist. <br /> | + | <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;">2.16.840.1.113883.3.1937.777.35.10.68</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2019‑05‑24 22:58:02</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;">ElektronischerImpfpassDiagnosis</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Diagnose (cdaab2)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beschreibung</th><td style="text-align: left;" colspan="3">Bildet eine Diagnose ab. Die Informationen hierzu stammen aus folgender Quelle: http://wiki.hl7.de/index.php?title=cdaab2:ICD-Diagnose_Entry_(Template)</td></tr><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 2.16.840.1.113883.3.1937.777.35.10.68</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 1 Konzept</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%;">eImpfpass-data​element-147</td><td style="vertical-align: top;" title="Elektronischer Impfpass / Diagnosen und Symptome / ">[[File:Kyellow.png|14px]] Datum </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Impfpass </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 3 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;">1.2.276.0.76.10.2029</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] CDA author (pmp)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">2.16.840.1.113883.10.12.321</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] CDA Participant (Body)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">2.16.840.1.113883.3.1937.777.35.10.69</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Diagnose Ausnahmebegründung</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">Spezialisierung: Template 2.16.840.1.113883.10.12.303 <i>CDA Observation </i> (2005‑09‑07) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">ad1bbr-</div></span></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</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppnamespace">hl7:</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="ppattribute">negationInd</span><span class="ppsign">="</span><span class="ppcontent">false</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.3.1937.777.35.10.68</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="ppnamespace">hl7:</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.3.999</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">--example only--</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="ppnamespace">hl7:</span><span class="ppelement">code</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.3.1937.777.35.11.17</span><span class="ppsign">"</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">DIA</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="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">></span><span class="pptext">text</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">true</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="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20190621112754</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</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">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.413</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">qualifier</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</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="ppnamespace">hl7:</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">1.2.276.0.76.11.121</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Gesichert</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">qualifier</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">targetSiteCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">R</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.11.412</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Rechts</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="ppnamespace">hl7:</span><span class="ppelement">author</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.2029</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Diagnosedatum 1..1 M --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">time</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20131020</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="ppnamespace">hl7:</span><span class="ppelement">assignedAuthor</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">id</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">720091905</span><span class="ppsign">"</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.4.16</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">assignedAuthor</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">author</span><span class="ppsign">></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">participant</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">ENT</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.10.12.321</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Dokumentationsdatum 1..1 R--><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">time</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20131020</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="ppnamespace">hl7:</span><span class="ppelement">participantRole</span><span class="ppsign">/</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">participant</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!-- Ausnhamebegündung 0..1 --><br /></span></span><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">RSON</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</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;" class="explrendered"> <span class="ppsign"><</span><span class="ppnamespace">hl7:</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.3.1937.777.35.10.69</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="ppnamespace">hl7:</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="ppnamespace">hl7:</span><span class="ppelement">value</span> <span class="ppattribute">xsi:type</span><span class="ppsign">="</span><span class="ppcontent">ST</span><span class="ppsign">"</span><span class="ppsign">></span><span class="pptext">value</span><span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">></span></span> <span class="ppsign"></</span><span class="ppnamespace">hl7:</span><span class="ppelement">entryRelationship</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace">hl7:</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="">(Ele...sis)</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: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><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>@negationInd<br /></strong></tt></td></tr></table></td><td>bl</td><td><span><strong>0 … 1</strong></span></td><td> </td><td style="vertical-align: top;" colspan="2">Das Attribut @negationInd ist vom Datentyp BL und hat damit die Ausprägungen "true" oder "false". Wird das Attribut mit „true" angegeben, so wird ausgesagt, dass die über die Observation-Klasse beschriebene Beobachtung negiert wird. In Bezug auf die Diagnosendarstellung bedeutet das, dass die beschriebene Diagnose nicht zutrifft. Die Angabe des Attributs ist optional. Wird es nicht angegeben, geht das empfangende System von dem Default-Wert aus und verwendet diesen zur weiteren Verarbeitung. Der Default–Wert ist „false".<br /></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>II</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="">(Ele...sis)</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">2.16.840.1.113883.3.1937.777.35.10.68</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>II</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>Über das Attribut id kann die Diagnose eine eindeutige Identifikation innerhalb eines Systems erhalten. Für die Verarbeitung von Diagnosedaten über ein rechnergestütztes System ist die Vergabe von Ids empfehlenswert, um gezielt auf den Datensatz der Diagnose zugreifen zu können. In der XML-Repräsentation wird die Diagnose-ID im Attribut @extension und die OID des Systems im Attribut @root angegeben. Sollen für Diagnosen später Änderungen oder Löschungen kommuniziert werden, ist eine eindeutige Referenzierung über diese Identifikation unerlässlich.</td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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>CD</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="">(Ele...sis)</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>@codeSystem<br /></strong></tt></td></tr></table></td><td>oid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">2.16.840.1.113883.3.1937.777.35.11.17</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>@code<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">DIA</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>ST</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Der erläuternde Text zu einer Diagnose wird über das Attribut @text abgebildet. Die strukturierte Darstellung sieht wie folgt aus.</td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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:statusCode<br /></strong></tt></td></tr></table></td><td><strong>CS</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>Über dieses Attribut wird der Status, in dem der beschriebene Act sich befindet, angegeben. Ein Act kann z.B. den Status „new", „active" oder „cancelled" besitzen. Die Beobachtung einer Diagnose wird mit der Dokumentation als abgeschlossene Handlung betrachtet. Somit wird für das Attribut statusCode der feste Wert „completed" vorgegeben.<br /></td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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>@code<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">true</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>IVL_TS</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 Attribute <i>effectiveTime</i> der Klasse <i>Observation</i> gibt den Zeitraum an, für den die beschriebene Beobachtung für den Patienten gültig (klinisch relevant) ist bzw. war. In Bezug auf die Darstellung einer Diagnose, handelt es sich um den Diagnosezeitraum, der über das Element <i>effectiveTime</i> abgebildet wird. Über das Unterelement <i>low</i> wird das Startdatum des Zeitraums angegeben, über das Unterelement <i>high</i> das Enddatum. Sowohl das Element <i>low</i> als auch das Element <i>high</i> können alleine angegeben werden</td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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;">eImpfpass-data​element-147</td><td style="vertical-align: top;" title="Elektronischer Impfpass / Diagnosen und Symptome / ">[[File:Kyellow.png|14px]] Datum </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Impfpass </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: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>M</strong></span></td><td>Die Darstellung eines Diagnosecodes und des zum Code gehörenden Text erfolgt über das Attribut <i>value</i> der Klasse <i>Observation</i>. Das XML-Attribut <i>@code</i> des Elements <i>value </i>enthält<i> </i>den Diagnosecode, das XML-Attribut <i>@displayName</i> enthält den zum Code gehörenden Text. Die strukturierte Darstellung für eine ICD-10 codierte Diagnose sieht wie folgt aus. </td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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>@codeSystem<br /></strong></tt></td></tr></table></td><td>oid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.276.0.76.5.413</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"><div>Default</div><tt><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">I01.0</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Akute rheumatische Perikarditis</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.5.413</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">originalText</span><span class="ppsign">></span><span class="pptext">......</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">originalText</span><span class="ppsign">></span></span><span style="display: block;"> <span style="color:green"><!--Diagnosesicherheit--><br /></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">2.16.840.1.113883.3.7.1.8</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></tt></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"><div>Freitext</div><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">value</span> <span class="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">NAV</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">originalText</span><span class="ppsign">></span><span class="pptext">Rektumkarzinom mit Höhenlokalisation ab Anokutanlinie/Linea dentata</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">originalText</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">value</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: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>R</strong></span></td><td>Die Angabe der Diagnosesicherheit wird über dieses Kindelement <i>qualifier</i> abgebildet. <br />Wenn Diagnosesicherheit "A" angegeben, muss <i>negationInd=true </i>gesetzt werden.<br />Wenn Diagnosesicherheit "V" angegeben, muss <i>Author.typeCode="AUTH" </i>gesetzt sein.<br /></td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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: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="">(Ele...sis)</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>CD</strong> (erforderlich)</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="">(Ele...sis)</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>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: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:originalText<br /></strong></tt></td></tr></table></td><td><strong>ST</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="">(Ele...sis)</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:target​Site​Code<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>Die Lokalisation zu Diagnosen wird über das Element targetSiteCode angegeben. Wird die Lokalisation im Freitext angegeben, erfolgt die Darstellung über das Unterelement orginalText. Bei fehlender Codierung muss im Element targetSiteCode das Attribut @nullFlavor angegeben werden.</td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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>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="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Beispiel</td><td colspan="4" class="explabelblue"><div>Default</div><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">targetSiteCode</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">2.16.840.1.113883.3.1937.777.35.11.18</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span></tt></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"><div>Freitext-Angabe</div><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">targetSiteCode</span> <span class="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">NI</span><span class="ppsign">"</span><span class="ppsign">></span><br /><span style="display: block;" class="explrendered"> <span class="ppsign"><</span><span class="ppelement">originalText</span><span class="ppsign">></span><span class="pptext">Oberhalb des rechten Knöchels</span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">originalText</span><span class="ppsign">></span></span><span class="ppsign"></</span><span class="ppnamespace"></span><span class="ppelement">targetSiteCode</span><span class="ppsign">></span></span></tt></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"><div>Systemerkrankung (bzw. im Sinne von „nicht zutreffend")</div><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">targetSiteCode</span> <span class="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">NA</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">></span></span></tt></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"><div>Unbekannt</div><tt><span style="display: block;" class="explrendered"><span class="ppsign"><</span><span class="ppelement">targetSiteCode</span> <span class="ppattribute">nullFlavor</span><span class="ppsign">="</span><span class="ppcontent">UNK</span><span class="ppsign">"</span><span class="ppsign">/</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:Treetree.png|16px]]</td><td><tt><strong>hl7:originalText<br /></strong></tt></td></tr></table></td><td><strong>ST</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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:author<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>Das Diagnosedatum wird über die Klasse <i>author</i> dargestellt, welche als <i>Participation</i> mit der Klasse <i>Observation</i> verbunden ist. <br /><h4><span class="mw-headline" id="Diagnosedatum">Diagnosedatum</span></h4><p>Das Diagnosedatum gibt an, wann die Krankheit diagnostiziert wurde. Das Diagnosedatum muss nicht gleich dem Dokumentationsdatum sein. <br /> Die Klasse <i>CDA Author Body</i> enthält ein Attribut <i>time</i> vom Datentyp IVL <TS>. Nähere Informationen zu der Person, welche die Krankheit diagnostiziert hat, können über die Klasse <i>assignedEntity</i> abgebildet werden. </p><br />Beinhaltet 1.2.276.0.76.10.2029 <i>CDA author (pmp)</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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> wo <i> [not(@nullFlavor)] [hl7:author]</i></td></tr></table></td><td></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:participant<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><h4><span class="mw-headline" id="Dokumentationsdatum">Dokumentationsdatum</span></h4><p>Das Dokumentationsdatum ist das Datum, an dem die Krankheit z.B. durch einen Arzt dokumentiert wurde. Diese Datumsangabe wird über die Klasse <i>dataEnterer</i>abgebildet, welche als <i>Participation</i> mit der Klasse <i>Observation</i> verknüpft ist (vgl. Abbildung 1: Klasse Observation).</p><p>Die Klasse <i>dataEnterer</i> enthält ein Attribut <i>time</i> vom Datentyp <i>TS</i>. D.h., dass in der XML-Struktur die Datumsangabe über einem Element <i>time</i> und dessen Attribute <i>@value</i> abgebildet wird.</p><p>Ist keine explizite Klasse <i>dataEnterer</i> vorhanden, so wird eine <i>Participation</i>-Klasse durch die Angabe des Attributes <i>typeCode</i> mit dem Wert ENT zu einer Klasse <i>dataEnterer</i>. Über die Klasse <i>paticipationRole</i> kann die Person näher beschrieben werden. </p><br />Beinhaltet 2.16.840.1.113883.10.12.321 <i>CDA Participant (Body)</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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> wo <i> [hl7:participantRole]</i></td></tr></table></td><td></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:entryRelationship<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><div><b>Ausnahmebegründung<br /></b></div><div>Die Begründung der abrechnungsrelevanten Ausnahme wird in dem Attribut @value einer Klasse Observation dargestellt, welche über eine ActRelationship-Klasse mit der diagnosebeschreibenden Klasse Observation verlinkt ist.</div><br />Beinhaltet 2.16.840.1.113883.3.1937.777.35.10.69 <i>Diagnose Ausnahmebegründung</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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> wo <i> [hl7:observation [hl7:code [(@code = 'ERSON' and @codeSystem = '2.16.840.1.113883.3.1937.777.35.11.12')]]]</i></td></tr></table></td><td></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>@typeCode<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">RSON</td></tr></table></td></tr></table> |
− | <h4> | ||
− | |||
− | </h4> | ||
− | <p>Das Diagnosedatum gibt an, wann die Krankheit diagnostiziert wurde. Das Diagnosedatum muss nicht gleich dem Dokumentationsdatum sein. <br /> Die Klasse <i>CDA Author Body</i> enthält ein Attribut <i>time</i> vom Datentyp IVL <TS>. Nähere Informationen zu der Person, welche die Krankheit diagnostiziert hat, können über die Klasse <i>assignedEntity</i> abgebildet werden. </p><br />Beinhaltet 1.2.276.0.76.10.2029 <i>CDA author (pmp)</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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> wo <i> [not(@nullFlavor)] [hl7:author]</i></td></tr></table></td><td></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:participant<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><h4> | ||
− | |||
− | </h4> | ||
− | <p>Das Dokumentationsdatum ist das Datum, an dem die Krankheit z.B. durch einen Arzt dokumentiert wurde. Diese Datumsangabe wird über die Klasse <i>dataEnterer</i>abgebildet, welche als <i>Participation</i> mit der Klasse <i>Observation</i> verknüpft ist (vgl. Abbildung 1: Klasse Observation).</p> | ||
− | <p>Die Klasse <i>dataEnterer</i> enthält ein Attribut <i>time</i> vom Datentyp <i>TS</i>. D.h., dass in der XML-Struktur die Datumsangabe über einem Element <i>time</i> und dessen Attribute <i>@value</i> abgebildet wird.</p> | ||
− | <p>Ist keine explizite Klasse <i>dataEnterer</i> vorhanden, so wird eine <i>Participation</i>-Klasse durch die Angabe des Attributes <i>typeCode</i> mit dem Wert ENT zu einer Klasse <i>dataEnterer</i>. Über die Klasse <i>paticipationRole</i> kann die Person näher beschrieben werden. </p><br />Beinhaltet 2.16.840.1.113883.10.12.321 <i>CDA Participant (Body)</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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> wo <i> [hl7:participantRole]</i></td></tr></table></td><td></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:entryRelationship<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><div> | ||
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− | </div> | ||
− | <div>Die Begründung der abrechnungsrelevanten Ausnahme wird in dem Attribut @value einer Klasse Observation dargestellt, welche über eine ActRelationship-Klasse mit der diagnosebeschreibenden Klasse Observation verlinkt ist.</div><br />Beinhaltet 2.16.840.1.113883.3.1937.777.35.10.69 <i>Diagnose Ausnahmebegründung</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Ele...sis)</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> wo <i> [hl7:observation [hl7:code [(@code = 'ERSON' and @codeSystem = '2.16.840.1.113883.3.1937.777.35.11.12')]]]</i></td></tr></table></td><td></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>@typeCode<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">RSON</td></tr></table></td></tr></table> |
Version vom 19. Juli 2019, 15:16 Uhr
Id | 2.16.840.1.113883.3.1937.777.35.10.68 | Gültigkeit | 2019‑05‑24 22:58:02 | ||
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Status | Entwurf | Versions-Label | |||
Name | ElektronischerImpfpassDiagnosis | Anzeigename | Diagnose (cdaab2) | ||
Beschreibung | Bildet eine Diagnose ab. Die Informationen hierzu stammen aus folgender Quelle: http://wiki.hl7.de/index.php?title=cdaab2:ICD-Diagnose_Entry_(Template) | ||||
Kontext | Elternknoten des Template-Element mit Id 2.16.840.1.113883.3.1937.777.35.10.68 | ||||
Klassifikation | CDA Entry Level Template | ||||
Offen/Geschlossen | Offen (auch andere als die definierten Elemente sind erlaubt) | ||||
Assoziiert mit |
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Benutzt |
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Beziehung | Spezialisierung: Template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07) ref ad1bbr- | ||||
Beispiel |
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