Beispiel
(Teildokument von Einweisung (Muster 06))
Dieses Material ist Teil des Leitfadens Einweisung (Muster 06).
|
vollständiges Beispiel
<?xml version="1.0" encoding="utf-8" standalone="yes"?>
<?xml-stylesheet type="text/xsl" href="vhitg-cda-v3.xsl"?>
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<realmCode code="DE"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="" assigningAuthorityName=""/>
<id root="" extension="" assigningAuthorityName=""/>
<code code="6" displayName="KBV Muster 6: Überweisung" codeSystem="999999999" codeSystemName=""/>
<title>Überweisung</title>
<effectiveTime value="20140207082015+0100"/>
<confidentialityCode code="N" displayName="normal" codeSystem="2.16.840.1.113883.5.25" codeSystemName="HL7:Confidentiality"/>
<languageCode code="de-DE"/>
<setId root="1.2.40.0.34.99.111.1.1" extension="134F989" assigningAuthorityName="Amadeus Spital"/>
<versionNumber value="1"/>
<recordTarget>
<patientRole>
<!--
IDs des Patienten
-->
<!-- Identifikation des Patienten im lokalen System -->
<id root="" extension="" assigningAuthorityName=""/>
<!-- Identifikation des Patienten in der Affinity Domain -->
<id root="" extension="" assigningAuthorityName=""/>
<!--
Adresse des Patienten
-->
<addr use="H">
<streetAddressLine>Musterstraße 13a</streetAddressLine>
<postalCode>12345</postalCode>
<city>Musterstadt</city>
<country>Deutschland</country>
</addr>
<patient>
<!--
Name des Patienten
-->
<name>
<prefix qualifier="AC">Dipl.Ing.</prefix>
<prefix qualifier="NB">Hofrat</prefix>
<given>Herbert</given>
<given>Hannes</given>
<family>Mustermann</family>
<family qualifier="BR">VorDerHeirat</family>
<suffix qualifier="AC">BSc</suffix>
<suffix qualifier="AC">MBA</suffix>
</name>
<!--
Geburtsdatum des Patienten
-->
<birthTime value="19611224"/>
</patient>
</patientRole>
</recordTarget>
<author>
<functionCode code="OA" displayName="Diensthabender Oberarzt" codeSystem="1.2.40.0.34.99.111.2.1" codeSystemName="Amadeus Spital - Funktionscodes"/>
<assignedAuthor>
<id root="1.2.40.0.34.99.111.1.3" extension="1111" assigningAuthorityName="Amadeus Spital"/>
<code code="107" displayName="Fachärztin/Facharzt für Chirurgie" codeSystem="1.2.40.0.34.5.2" codeSystemName="gda-rollen"/>
<telecom use="WP" value="tel:+43.6138.3453446.1111"/>
<assignedPerson>
<!-- Name des Verfassers des Dokuments -->
<name>
<prefix>Dr.</prefix>
<given>Isabella</given>
<family>Stern</family>
</name>
</assignedPerson>
<representedOrganization>
<name>Amadeus Spital - Chirurgische Abteilung</name>
<telecom value="tel:+43.6138.3453446.0"/>
<telecom value="fax:+43.6138.3453446.4674"/>
<telecom value="mailto:info@amadeusspital.at"/>
<telecom value="http://www.amadeusspital.at"/>
<addr>
<streetName>Mozartgasse</streetName>
<houseNumber>1-7</houseNumber>
<postalCode>5350</postalCode>
<city>St.Wolfgang</city>
<state>Salzburg</state>
<country>Österreich</country>
</addr>
</representedOrganization>
</assignedAuthor>
</author>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="1.2.40.0.34.99.3" assigningAuthorityName="GDA Index"/>
<name>Amadeus Spital</name>
<telecom value="tel:+43.6138.3453446.0"/>
<addr>
<streetName>Mozartgasse</streetName>
<houseNumber>1-7</houseNumber>
<postalCode>5350</postalCode>
<city>St.Wolfgang</city>
<state>Salzburg</state>
<country>Österreich</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<participant typeCode="HLD">
<templateId root="1.2.40.0.34.11.1.1.6"/>
<!-- Versicherungszeitraum vom 01.01.2002 – 31.12.2013 -->
<time>
<low value="20020101"/>
<high value="20131231"/>
</time>
<associatedEntity classCode="POLHOLD">
<!-- Sozialversicherungsnummer des Patienten -->
<id root="1.2.40.0.10.1.4.3.1" extension="123424121961" assigningAuthorityName="Österreichische Sozialversicherung"/>
<!-- Code SELF (Patient ist selbst der Versicherungsnehmer) -->
<code code="SELF" displayName="self" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7:RoleCode"/>
<!-- Versicherungsgesellschaft -->
<scopingOrganization>
<name>Sozialversicherung der gew. Wirtschaft</name>
<telecom value="tel:01.54654.0"/>
<telecom value="fax:01.54654.385"/>
<telecom value="http://esv-sva.sozvers.at"/>
<addr>
<streetName>Wiedner Hauptstraße</streetName>
<houseNumber>84-86</houseNumber>
<postalCode>1051</postalCode>
<city>Wien</city>
<state>Wien</state>
<country>Österreich</country>
</addr>
</scopingOrganization>
</associatedEntity>
</participant>
<component>
<structuredBody>
<!-- Fragestellung -->
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.1"/>
<!-- ** Reason for Referral Section Template ** -->
<code
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
code="42349-1"
displayName="REASON FOR REFERRAL"/>
<title>REASON FOR REFERRAL</title>
<!-- Unstructured text field -->
<text>
<paragraph>Follow up with Dr George Potomac for Asthma</paragraph>
</text>
<!-- Zweck -->
<entry>
<observation>
<code code="????" displayName="Zweck" codesystem="" />
<value xsi:type="CD" code="2" codeSystem="9999999" displayName="Notfall">
</observation>
</entry>
<!-- Untersuchungsart -->
<entry>
<observation>
<code code="????" displayName="Untersuchungsart" codesystem="" />
<value xsi:type="CD" code="1" codeSystem="9999999" displayName="Auftragsleistung">
</observation>
</entry>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>
