cdaeau:Beispiel
Nachfolgend ein Beispieldokument:
1<?xml version="1.0" encoding="UTF-8"?>
2<?xml-stylesheet type="text/xsl" href="eau.xslt"?>
3<?xml-model href="../../abde-runtime-develop/abde-abplus.sch" type="application/xml" schematypens="http://purl.oclc.org/dsdl/schematron"?>
4<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:pharm="urn:ihe:pharm:medication" xsi:schemaLocation="urn:hl7-org:v3 ../schemas/CDA.xsd">
5 <realmCode code="DE"/>
6 <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
7 <templateId root="1.2.276.0.76.10.1020"/>
8 <id root="1.2.276.0.76.3645.239" extension="di-b02e97c1-3cea-4ed4-80cd-5d8a7386cee2" />
9 <code code="xERST_END" codeSystem="2.16.840.1.113883.6.1" displayName="Arbeitsunfähigkeitserst-/-endbescheinigung"/>
10 <title>eAU vom 25. Oktober 2017</title>
11 <effectiveTime value="20171025123415"/>
12 <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
13 <languageCode code="de-DE"/>
14 <setId root="1.2.276.0.76.3645.239" extension="si-b8a7b265-4e20-4177-8cfb-149491b8003a"/>
15 <versionNumber value="1"/>
16 <recordTarget>
17 <patientRole>
18 <id extension="1543627549" root="1.2.276.0.76.4.1"/>
19 <addr>
20 <streetAddressLine>Riedemannweg 59</streetAddressLine>
21 <postalCode>13627</postalCode>
22 <city>Berlin</city>
23 </addr>
24 <telecom use="HP" value="tel:030.456.345345"/>
25 <patient>
26 <name>
27 <given>Paul</given>
28 <family>Pappel</family>
29 </name>
30 <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
31 <birthTime value="19551217"/>
32 <birthplace>
33 <place>
34 <addr>
35 <city>Sassnitz</city>
36 </addr>
37 </place>
38 </birthplace>
39 </patient>
40 </patientRole>
41 </recordTarget>
42 <author>
43 <!--- author -->
44 <time value="20151104"/>
45 <assignedAuthor>
46 <id extension="ied8984938" root="2.16.840.1.113883.3.67.933"/>
47 <assignedPerson>
48 <name>
49 <prefix qualifier="AC">Dr. med.</prefix>
50 <given>Theo</given>
51 <family>Phyllin</family>
52 </name>
53 </assignedPerson>
54 <representedOrganization>
55 <id extension="1443984938" root="BSNR"/>
56 <name>Praxis Dr. med. Phyllin</name>
57 <telecom use="WP" value="tel:0214.2127070"/>
58 <telecom use="WP" value="tel:0214.212707122"/>
59 <addr>
60 <streetName>Krankenhausstraße</streetName>
61 <houseNumber>240</houseNumber>
62 <postalCode>51371</postalCode>
63 <city>Leverkusen</city>
64 </addr>
65 </representedOrganization>
66 </assignedAuthor>
67 </author>
68 <custodian>
69 <assignedCustodian>
70 <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
71 <id extension="M345" root="1.2.276.0.58"/>
72 <name>Praxis Dr. med. Phyllin</name>
73 <telecom use="WP" value="tel:0214.2127070"/>
74 <addr>
75 <streetName>Krankenhausstraße</streetName>
76 <houseNumber>240</houseNumber>
77 <postalCode>51371</postalCode>
78 <city>Leverkusen</city>
79 </addr>
80 </representedCustodianOrganization>
81 </assignedCustodian>
82 </custodian>
83 <legalAuthenticator typeCode="LA" contextControlCode="OP">
84 <time value="20171004"/>
85 <signatureCode code="S"/>
86 <assignedEntity>
87 <!-- nur als ID (identisch zu author) -->
88 <id extension="ied8984938" root="2.16.840.1.113883.3.67.933"/>
89 </assignedEntity>
90 </legalAuthenticator>
91 <component>
92 <structuredBody>
93 <!-- Versicherung Section -->
94 <component typeCode="COMP" >
95 <section>
96 <templateId root="???????"/>
97 <code code="48768-0" codeSystem="2.16.840.1.113883.6.1"/>
98 <title>Versicherung</title>
99 <!-- Versicherung/Coverage -->
100 <entry>
101 <act classCode="ACT" moodCode="EVN">
102 <templateId/>
103 <id/>
104 <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" />
105 <statusCode code="completed"/>
106 <entryRelationship typeCode="COMP" sequenceNumber="1">
107 <!-- Versicherungspolicy -->
108 <act>
109 <templateId root="VERSICHERUNG" />
110 <code code="" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
111 <statusCode code="completed"/>
112 <!-- Payer Information -->
113 <performer>
114 <assignedEntity>
115 <id extension="Kassen-ID-47" />
116 <addr>
117 <streetAddressLine>AOK-Weg 1459</streetAddressLine>
118 <postalCode>10111</postalCode>
119 <city>Berlin</city>
120 </addr>
121 <representedOrganization>
122 <name>Versicherung AOK Berlin</name>
123 </representedOrganization>
124 </assignedEntity>
125 </performer>
126 <!-- Guarantor -->
127 <performer/>
128 <!-- Versicherung -->
129 <participant typeCode="COV">
130 <time>
131 <high value="20181231"/>
132 </time>
133 <participantRole>
134 <!-- Versichertenstatus -->
135 <code code="1"/>
136 </participantRole>
137 </participant>
138 <!-- Versicherter -->
139 <participant typeCode="HLD">
140 <participantRole>
141 <id extension="VNR=4711">fgsdff</id>
142 </participantRole>
143 </participant>
144 <entryRelationship>
145 <!-- Person Group Observation -->
146 <observation>
147 <templateId root="PRSNGRP" />
148 <code code="PRSNGRP" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
149 <value code="P" codeSystem="S_KBV_PERSONENGRUPPE"/>
150 </observation>
151 </entryRelationship>
152 <entryRelationship>
153 <!-- DMP Observation -->
154 <observation>
155 <templateId root="DMP" />
156 <code code="DMP" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
157 <value code="D" codeSystem="S_KBV_DMP"/>
158 </observation>
159 </entryRelationship>
160 <entryRelationship>
161 <!-- DMP Observation -->
162 <observation>
163 <templateId root="ASV" />
164 <code code="ASV" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
165 <value code="A" codeSystem="S_KBV_DMP"/>
166 </observation>
167 </entryRelationship>
168 </act>
169 </entryRelationship>
170 </act>
171 </entry>
172 </section>
173 </component>
174 <!-- AU-Diagnose Section -->
175 <component>
176 <section>
177 <templateId root=""/>
178 <code code="AU-DIAGNOSIS" />
179 <title>AU-begründende Diagnosen</title>
180 <text>Der Patient will einfach nicht arbeiten!</text>
181 <entry>
182 <observation classCode="OBS" moodeCode="EVN">
183 <code code="x47"/>
184 <statusCode code="completed"/>
185 </observation>
186 </entry>
187 <entry>
188 <observation classCode="OBS" moodeCode="EVN">
189 <code code="x80"/>
190 <statusCode code="completed"/>
191 </observation>
192 </entry>
193 </section>
194 </component>
195 <!-- Findings Section -->
196 <component>
197 <section>
198 <templateId/>
199 <text>
200
201 </text>
202 </section>
203 </component>
204 <!-- Accident/Unfall Section -->
205 <component>
206 <section>
207 <templateId/>
208 <code code="ACCIDENT"/>
209 <title>Unfall</title>
210 <entry>
211 <observation>
212 <templateId/>
213 <code code="ACCIDENT"/>
214 <statusCode code="completed"/>
215 <effectiveTime/>
216 <value code="D-ARZT" codeSystem="S_KBV_01_Accident"/>
217 </observation>
218 </entry>
219 </section>
220 </component>
221 <!-- Treatment Section -->
222 <component>
223 <section>
224 <templateId/>
225 <code code="TREATMENT"/>
226 <title>Einleitung besonderer Maßnahmen</title>
227 <text>
228 keine Ahnung, was sonst noch zu tun ist
229 </text>
230 <!-- Treatment stufenweise Wiedereingliederung -->
231 <entry>
232 <observation>
233 <code code="EINGLIEDERUNG" />
234 <value xsi:type="BL" value="false"/>
235 </observation>
236 </entry>
237 <!-- Treatment Leistungen med. Reha Observation -->
238 <entry>
239 <observation>
240 <code code="REHA" />
241 <value xsi:type="BL" value="true"/>
242 </observation>
243 </entry>
244 </section>
245 </component>
246 <!-- Temporary Disablement Section -->
247 <component>
248 <section>
249 <templateId/>
250 <code code="TEMPDISABLE"/>
251 <title>Arbeitsunfähigkeit</title>
252 <entry>
253 <observation>
254 <code code="X-IATWRK" codeSystem="2.16.840.1.113883.6.1"/>
255 <statusCode code="completed"/>
256 <text>
257
258 </text>
259 <effectiveTime>
260 <!-- Zeitraum der Arbeitsunfähigkeit -->
261 <low value="20171018"/>
262 <high value="20171020"/>
263 </effectiveTime>
264 <value xsi:type="INT" unit="%" value="100" />
265 <performer>
266 <!-- festgestellt am -->
267 <time value="20171019"/>
268 <assignedEntity>
269 <id/>
270 <assignedPerson>
271 <name>Hugo Müller</name>
272 </assignedPerson>
273 </assignedEntity>
274 </performer>
275 </observation>
276 </entry>
277 </section>
278 </component>
279 </structuredBody>
280 </component>
281</ClinicalDocument>
