Beispieldokument Arztmeldung
(Teildokument von Übermittlung meldepflichtiger Krankheiten)
Dieses Material ist Teil des Leitfadens Übermittlung meldepflichtiger Krankheiten.
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Beispieldokument
<?xml version="1.0" encoding="UTF-8"?>
<?xml-stylesheet type="text/xsl" href="rki-cda-v3.xsl"?>
<ClinicalDocument xmlns="urn:hl7-org:v3"
xmlns:sciphox="urn::sciphox-org/sciphox"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
<typeId root="2.16.840.1.113883.1.3"
extension="POCD_HD000040"/>
<id extension="60467,36049" root="1.2.276.0.58"/>
<code code="11488-4" codeSystem="2.16.840.1.113883.6.1"
displayName="Consultation note"/>
<title>Meldeformular für RKI auf CDA Rel.2 Basis</title>
<effectiveTime value="20060924"/>
<confidentialityCode code="N"
codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="de"/>
<setId extension="D1" root="2.16.840.1.113883.3.933"/>
<versionNumber value="1"/>
<recordTarget>
<!--- Patienten-Daten -->
<patientRole>
<id extension="6" root="2.16.840.1.113883.3.933"/>
<telecom use="WP" value="tel:040-555-12345"/>
<telecom use="HP" value="tel:040-222-76543"/>
<addr>
<streetName>Steinstr.</streetName>
<houseNumber/>
<postalCode>30156</postalCode>
<city>Hamburg</city>
</addr>
<patient>
<name>
<prefix>Dr.</prefix>
<given>Alfred</given>
<family>Hafer</family>
</name>
<administrativeGenderCode code="M"
codeSystem="2.16.840.1.113883.5.1"/>
<birthTime value="19450601"/>
</patient>
<providerOrganization>
<telecom use="WP" value="tel:061511111111"/>
<telecom use="WP" value="fax:061512222222"/>
<addr>
<streetName>Musterstr.</streetName>
<houseNumber>1</houseNumber>
<postalCode>64283</postalCode>
<city>Darmstadt</city>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author>
<!--- author -->
<time value="20060924"/>
<assignedAuthor>
<id extension="6319123" root="2.16.840.1.113883.3.933"/>
<assignedPerson>
<name>
<prefix>Dr.med. Hans</prefix>
<given/>
<family>Topp-Glücklich</family>
</name>
</assignedPerson>
<representedOrganization>
<name>Dr.med. Hans Topp-Glücklich </name>
<telecom use="WP" value="tel:061511111111"/>
<telecom use="WP" value="fax:061512222222"/>
<addr>
<streetName>Musterstr.</streetName>
<houseNumber>1</houseNumber>
<postalCode>64283</postalCode>
<city>Darmstadt</city>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
<custodian>
<!--- Organisation von der das Dokument stammt -->
<assignedCustodian>
<representedCustodianOrganization>
<id extension="M345" root="1.2.276.0.58"/>
<name>Dr.med. Hans Topp-Glücklich </name>
<telecom nullFlavor="UNK"/>
<addr>
<streetName>Musterstr.</streetName>
<houseNumber>1</houseNumber>
<postalCode>64283</postalCode>
<city>Darmstadt</city>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<informationRecipient typeCode="PRCP">
<!--- Empfaenger -->
<intendedRecipient>
<id extension="21233445"
root="2.16.840.1.113883.3.933"/>
<receivedOrganization>
<telecom use="WP" value="fax:02431/901-6210"/>
<name>
Landeshauptstadt Kiel<delimiter/>
Amt für Gesundheit<delimiter/>
Infektionsschutz/Umwelthygiene
</name>
<addr>
<postBox>11 52</postBox>
<postalCode>24099</postalCode>
<city>Kiel</city>
</addr>
</receivedOrganization>
</intendedRecipient>
</informationRecipient>
<legalAuthenticator>
<!--- legalAuthenticator -->
<time value="20060721"/>
<signatureCode code="S"/>
<assignedEntity>
<id extension="6319123" root="2.16.840.1.113883.3.933"/>
<assignedPerson>
<name>
<prefix>Dr.med. Hans</prefix>
<given/>
<family>Topp-Glücklich</family>
</name>
</assignedPerson>
<representedOrganization>
<name>Dr.med. Hans Topp-Glücklich </name>
<telecom use="WP" value="fax:061512222222"/>
<addr>
<streetName>Musterstr.</streetName>
<houseNumber>1</houseNumber>
<postalCode>64283</postalCode>
<city>Darmstadt</city>
</addr>
</representedOrganization>
</assignedEntity>
</legalAuthenticator>
<component>
<structuredBody>
<component>
<!-- meldepflichtige Krankheiten auf CDA Level 2 -->
<section>
<templateID root="1.2.276.0.76.3.1.81.1.4.1"/>
<code code="08"
codeSystem="1.2.276.0.76.3.1.81.1.3.1"
codeSystemName="RKI meldepflichtige Krankheiten"/>
<title>Botulismus</title>
<text><content ID="ND_200801"/></text>
</section>
<section>
<templateID root="1.2.276.0.76.3.1.81.1.4.1"/>
<code code="48"
codeSystem="1.2.276.0.76.3.1.81.1.3.1"
codeSystemName="RKI meldepflichtige Krankheiten"/>
<title>Cholera</title>
<text ><content ID="ND_200802"/></text>
</section>
<section>
<templateID root="1.2.276.0.76.3.1.81.1.4.1"/>
<code code="34"
codeSystem="1.2.276.0.76.3.1.81.1.3.1"
codeSystemName="RKI meldepflichtige Krankheiten"/>
<title>Masern</title>
<text>
<list>
<item>Respiratorsiche Symptomatik
<content ID="ND_200803"/>
</item>
</list>
</text>
<!-- Laborwert auf Level 3 -->
<entry>
<act classCode="ACT" moodCode="EVN">
<code code="B05.9" codeSystem="2.16.840.1.?????"
codeSystemName="ICD"
displayName="Respiratische Symptomatik"/>
<statusCode code="completed"/>
<entryRelationship typeCode="COMP">
<observation classCode="OBS" moodCode="EVN">
<code code="B05.9"
codeSystem="2.16.840.1.????"
codeSystemName="ICD"
displayName="Masern ohne komplikationen">
<originalText>
<reference value="#ND_200803"/>
</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime>
<center value="200801241025"/>
</effectiveTime>
<interpretationCode code="H"
codeSystem="2.16.840.1.113883.5.83"/>
</observation>
</entryRelationship>
</act>
</entry>
</section>
<section>
<templateID root="1.2.276.0.76.3.1.81.1.4.3"/>
<code code="M"
codeSystem="1.2.276.0.76.3.1.81.1.3.4"
codeSystemName="working place"/>
<title>Epidemiologische Situation</title>
<text>Patient ist im medizinischen Bereich tätig.
<content ID="ND_200804"/>
</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>
