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&#8203;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">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><span class="pptext">text</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</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">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">author</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Diagnosedatum 1..1 M --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">assignedAuthor</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">assignedAuthor</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">author</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Dokumentationsdatum 1..1 R--&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">participantRole</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">participant</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- Ausnhamebegündung 0..1 --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span><span class="pptext">value</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">&gt;</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&#8203;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">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span><span class="pptext">......</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!--Diagnosesicherheit--&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</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">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">value</span><span class="ppsign">&gt;</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">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span><span class="pptext">Rektumkarzinom mit Höhenlokalisation ab Anokutanlinie/Linea dentata</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">value</span><span class="ppsign">&gt;</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&#8203;Site&#8203;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">&lt;</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">&gt;</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">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span><span class="pptext">Oberhalb des rechten Knöchels</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">targetSiteCode</span><span class="ppsign">&gt;</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">&lt;</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">&gt;</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">&lt;</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">&gt;</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&#8203;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">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><span class="pptext">text</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</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">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">author</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Diagnosedatum 1..1 M --&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">assignedAuthor</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">assignedAuthor</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">author</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Dokumentationsdatum 1..1 R--&gt;<br /></span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppnamespace">hl7:</span><span class="ppelement">participantRole</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">participant</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- Ausnhamebegündung 0..1 --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</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">&gt;</span><span class="pptext">value</span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">value</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace">hl7:</span><span class="ppelement">observation</span><span class="ppsign">&gt;</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&#8203;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">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span><span class="pptext">......</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!--Diagnosesicherheit--&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</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">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</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">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">qualifier</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">value</span><span class="ppsign">&gt;</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">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span><span class="pptext">Rektumkarzinom mit Höhenlokalisation ab Anokutanlinie/Linea dentata</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">value</span><span class="ppsign">&gt;</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&#8203;Site&#8203;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">&lt;</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">&gt;</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">&lt;</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">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span><span class="pptext">Oberhalb des rechten Knöchels</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">originalText</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">targetSiteCode</span><span class="ppsign">&gt;</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">&lt;</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">&gt;</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">&lt;</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">&gt;</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 &lt;TS&gt;.  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>
 
    <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 &lt;TS&gt;.  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>
 

Version vom 19. Juli 2019, 15:16 Uhr

Id2.16.840.1.113883.3.1937.777.35.10.68Gültigkeit2019‑05‑24 22:58:02
StatusKyellow.png EntwurfVersions-Label
NameElektronischerImpfpassDiagnosisAnzeigenameDiagnose (cdaab2)
BeschreibungBildet eine Diagnose ab. Die Informationen hierzu stammen aus folgender Quelle: http://wiki.hl7.de/index.php?title=cdaab2:ICD-Diagnose_Entry_(Template)
KontextElternknoten des Template-Element mit Id 2.16.840.1.113883.3.1937.777.35.10.68
KlassifikationCDA Entry Level Template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Assoziiert mit
Assoziiert mit 1 Konzept
IdNameDatensatz
eImpfpass-data​element-147Kyellow.png Datum Kyellow.png Impfpass
Benutzt
Benutzt 3 Templates
Benutzt als NameVersion
1.2.276.0.76.10.2029ContainmentKyellow.png CDA author (pmp)DYNAMIC
2.16.840.1.113883.10.12.321ContainmentKgreen.png CDA Participant (Body)DYNAMIC
2.16.840.1.113883.3.1937.777.35.10.69ContainmentKyellow.png Diagnose AusnahmebegründungDYNAMIC
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
Beispiel
Beispiel
<hl7:observation classCode="OBS" moodCode="EVN" negationInd="false">
  <hl7:templateId root="2.16.840.1.113883.3.1937.777.35.10.68"/>  <hl7:id root="1.2.3.999" extension="--example only--"/>  <hl7:code codeSystem="2.16.840.1.113883.3.1937.777.35.11.17" code="DIA"/>  <hl7:text>text</hl7:text>  <hl7:statusCode code="true"/>  <hl7:effectiveTime>
    <hl7:low value="20190621112754"/>  </hl7:effectiveTime>
  <hl7:value xsi:type="CD" codeSystem="1.2.276.0.76.5.413">
    <hl7:qualifier>
      <hl7:name code="8" codeSystem="2.16.840.1.113883.3.7.1.0"/>      <hl7:value code="G" codeSystem="1.2.276.0.76.11.121" displayName="Gesichert"/>    </hl7:qualifier>
  </hl7:value>
  <hl7:targetSiteCode code="R" codeSystem="1.2.276.0.76.11.412" displayName="Rechts"/>  <hl7:author>
    <hl7:templateId root="1.2.276.0.76.10.2029"/>    <!-- Diagnosedatum 1..1 M -->
    <hl7:time value="20131020"/>    <hl7:assignedAuthor>
      <hl7:id extension="720091905" root="1.2.276.0.76.4.16"/>    </hl7:assignedAuthor>
  </hl7:author>
  <hl7:participant typeCode="ENT">
    <hl7:templateId root="2.16.840.1.113883.10.12.321"/>    <!-- Dokumentationsdatum 1..1 R-->
    <hl7:time value="20131020"/>    <hl7:participantRole/>  </hl7:participant>
  <!-- Ausnhamebegündung 0..1 -->
  <hl7:entryRelationship typeCode="RSON">
    <hl7:observation classCode="OBS" moodCode="EVN">
      <hl7:templateId root="2.16.840.1.113883.3.1937.777.35.10.69"/>      <hl7:statusCode code="completed"/>      <hl7:value xsi:type="ST">value</hl7:value>    </hl7:observation>
  </hl7:entryRelationship>
</hl7:observation>
ItemDTKardKonfBeschreibungLabel
hl7:observation
(Ele...sis)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 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".
Treetree.pnghl7:templateId
II1 … 1M(Ele...sis)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.3.1937.777.35.10.68
Treetree.pnghl7:id
II1 … 1RÜber 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.(Ele...sis)
Treetree.pnghl7:code
CD1 … 1M(Ele...sis)
Treeblank.pngTreetree.png@codeSystem
oid1 … 1F2.16.840.1.113883.3.1937.777.35.11.17
Treeblank.pngTreetree.png@code
cs1 … 1FDIA
Treetree.pnghl7:text
ST0 … 1Der erläuternde Text zu einer Diagnose wird über das Attribut @text abgebildet. Die strukturierte Darstellung sieht wie folgt aus.(Ele...sis)
Treetree.pnghl7:statusCode
CS1 … 1MÜber 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.
(Ele...sis)
Treeblank.pngTreetree.png@code
cs1 … 1Ftrue
Treetree.pnghl7:effectiveTime
IVL_TS0 … 1Das Attribute effectiveTime der Klasse Observation 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 effectiveTime abgebildet wird. Über das Unterelement low wird das Startdatum des Zeitraums angegeben, über das Unterelement high das Enddatum. Sowohl das Element low als auch das Element high können alleine angegeben werden(Ele...sis)
 
Target.png
eImpfpass-data​element-147Kyellow.png Datum Kyellow.png Impfpass
Treetree.pnghl7:value
CD1 … 1MDie Darstellung eines Diagnosecodes und des zum Code gehörenden Text erfolgt über das Attribut value der Klasse Observation. Das XML-Attribut @code des Elements value enthält den Diagnosecode, das XML-Attribut @displayName enthält den zum Code gehörenden Text. Die strukturierte Darstellung für eine ICD-10 codierte Diagnose sieht wie folgt aus. (Ele...sis)
Treeblank.pngTreetree.png@codeSystem
oid1 … 1F1.2.276.0.76.5.413
 Beispiel
Default
<value code="I01.0" displayName="Akute rheumatische Perikarditis" codeSystem="1.2.276.0.76.5.413">
  <originalText>......</originalText>  <!--Diagnosesicherheit-->
  <qualifier>
    <name code="8" codeSystem="2.16.840.1.113883.3.7.1.0"/>    <value code="G" codeSystem="2.16.840.1.113883.3.7.1.8"/>  </qualifier>
</value>
 Beispiel
Freitext
<value nullFlavor="NAV">
  <originalText>Rektumkarzinom mit Höhenlokalisation ab Anokutanlinie/Linea dentata</originalText></value>
Treeblank.pngTreetree.pnghl7:qualifier
CR0 … 1RDie Angabe der Diagnosesicherheit wird über dieses Kindelement qualifier abgebildet. 
Wenn Diagnosesicherheit "A" angegeben, muss negationInd=true gesetzt werden.
Wenn Diagnosesicherheit "V" angegeben, muss Author.typeCode="AUTH" gesetzt sein.
(Ele...sis)
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CV1 … 1M(Ele...sis)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF1 … 1F8
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.3.7.1.0
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD (erforderlich)1 … 1M(Ele...sis)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 1.2.276.0.76.11.121 S_ICD_DIAGNOSESICHERHEIT (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:originalText
ST(Ele...sis)
Treetree.pnghl7:target​Site​Code
CV1 … 1RDie 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.(Ele...sis)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 1.2.276.0.76.11.412 Lateralität (DYNAMIC)
 Beispiel
Default
<targetSiteCode code="L" codeSystem="2.16.840.1.113883.3.1937.777.35.11.18"/>
 Beispiel
Freitext-Angabe
<targetSiteCode nullFlavor="NI">
  <originalText>Oberhalb des rechten Knöchels</originalText></targetSiteCode>
 Beispiel
Systemerkrankung (bzw. im Sinne von „nicht zutreffend")
<targetSiteCode nullFlavor="NA"/>
 Beispiel
Unbekannt
<targetSiteCode nullFlavor="UNK"/>
Treeblank.pngTreetree.pnghl7:originalText
ST0 … 1(Ele...sis)
Treetree.pnghl7:author
1 … 1MDas Diagnosedatum wird über die Klasse author dargestellt, welche als Participation mit der Klasse Observation verbunden ist. 

Diagnosedatum

Das Diagnosedatum gibt an, wann die Krankheit diagnostiziert wurde. Das Diagnosedatum muss nicht gleich dem Dokumentationsdatum sein.
Die Klasse CDA Author Body enthält ein Attribut time vom Datentyp IVL <TS>. Nähere Informationen zu der Person, welche die Krankheit diagnostiziert hat, können über die Klasse assignedEntity abgebildet werden. 


Beinhaltet 1.2.276.0.76.10.2029 CDA author (pmp) (DYNAMIC)
(Ele...sis)
Treeblank.png wo [not(@nullFlavor)] [hl7:author]
Treetree.pnghl7:participant
1 … 1R

Dokumentationsdatum

Das Dokumentationsdatum ist das Datum, an dem die Krankheit z.B. durch einen Arzt dokumentiert wurde. Diese Datumsangabe wird über die Klasse dataEntererabgebildet, welche als Participation mit der Klasse Observation verknüpft ist (vgl. Abbildung 1: Klasse Observation).

Die Klasse dataEnterer enthält ein Attribut time vom Datentyp TS. D.h., dass in der XML-Struktur die Datumsangabe über einem Element time und dessen Attribute @value abgebildet wird.

Ist keine explizite Klasse dataEnterer vorhanden, so wird eine Participation-Klasse durch die Angabe des Attributes typeCode mit dem Wert ENT zu einer Klasse dataEnterer. Über die Klasse paticipationRole kann die Person näher beschrieben werden. 


Beinhaltet 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC)
(Ele...sis)
Treeblank.png wo [hl7:participantRole]
Treetree.pnghl7:entryRelationship
0 … 1
Ausnahmebegründung
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.

Beinhaltet 2.16.840.1.113883.3.1937.777.35.10.69 Diagnose Ausnahmebegründung (DYNAMIC)
(Ele...sis)
Treeblank.png wo [hl7:observation [hl7:code [(@code = 'ERSON' and @codeSystem = '2.16.840.1.113883.3.1937.777.35.11.12')]]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FRSON