cdaeau:Beispiel
Version vom 1. Dezember 2017, 13:33 Uhr von Wikiadmin (Diskussion | Beiträge)
Nachfolgend ein Beispieldokument:
1<?xml version="1.0" encoding="UTF-8"?>
2<?xml-stylesheet type="text/xsl" href="eau.xslt"?>
3<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">
4 <realmCode code="DE"/>
5 <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
6 <templateId root="1.2.276.0.76.10.1020"/>
7 <id root="1.2.276.0.76.3645.239" extension="di-b02e97c1-3cea-4ed4-80cd-5d8a7386cee2" />
8 <code code="xERST_END" codeSystem="2.16.840.1.113883.6.1" displayName="Arbeitsunfähigkeitserst-/-endbescheinigung"/>
9 <title>eAU vom 25. Oktober 2017</title>
10 <effectiveTime value="20171025123415"/>
11 <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
12 <languageCode code="de-DE"/>
13 <setId root="1.2.276.0.76.3645.239" extension="si-b8a7b265-4e20-4177-8cfb-149491b8003a"/>
14 <versionNumber value="1"/>
15 <recordTarget>
16 <patientRole>
17 <id extension="1543627549" root="1.2.276.0.76.4.1"/>
18 <addr>
19 <streetAddressLine>Riedemannweg 59</streetAddressLine>
20 <postalCode>13627</postalCode>
21 <city>Berlin</city>
22 </addr>
23 <telecom use="HP" value="tel:030.456.345345"/>
24 <patient>
25 <name>
26 <given>Paul</given>
27 <family>Pappel</family>
28 </name>
29 <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
30 <birthTime value="19551217"/>
31 <birthplace>
32 <place>
33 <addr>
34 <city>Sassnitz</city>
35 </addr>
36 </place>
37 </birthplace>
38 </patient>
39 </patientRole>
40 </recordTarget>
41 <author>
42 <!--- author -->
43 <time value="20151104"/>
44 <assignedAuthor>
45 <id extension="ied8984938" root="2.16.840.1.113883.3.67.933"/>
46 <assignedPerson>
47 <name>
48 <prefix qualifier="AC">Dr. med.</prefix>
49 <given>Theo</given>
50 <family>Phyllin</family>
51 </name>
52 </assignedPerson>
53 <representedOrganization>
54 <id extension="1443984938" root="BSNR"/>
55 <name>Praxis Dr. med. Phyllin</name>
56 <telecom use="WP" value="tel:0214.2127070"/>
57 <telecom use="WP" value="tel:0214.212707122"/>
58 <addr>
59 <streetName>Krankenhausstraße</streetName>
60 <houseNumber>240</houseNumber>
61 <postalCode>51371</postalCode>
62 <city>Leverkusen</city>
63 </addr>
64 </representedOrganization>
65 </assignedAuthor>
66 </author>
67 <custodian>
68 <assignedCustodian>
69 <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
70 <id extension="M345" root="1.2.276.0.58"/>
71 <name>Praxis Dr. med. Phyllin</name>
72 <telecom use="WP" value="tel:0214.2127070"/>
73 <addr>
74 <streetName>Krankenhausstraße</streetName>
75 <houseNumber>240</houseNumber>
76 <postalCode>51371</postalCode>
77 <city>Leverkusen</city>
78 </addr>
79 </representedCustodianOrganization>
80 </assignedCustodian>
81 </custodian>
82 <legalAuthenticator typeCode="LA" contextControlCode="OP">
83 <time value="20171004"/>
84 <signatureCode code="S"/>
85 <assignedEntity>
86 <!-- nur als ID (identisch zu author) -->
87 <id extension="ied8984938" root="2.16.840.1.113883.3.67.933"/>
88 </assignedEntity>
89 </legalAuthenticator>
90 <component>
91 <structuredBody>
92 <!-- Versicherung Section -->
93 <component typeCode="COMP" >
94 <section>
95 <templateId root="xxxxxx"/>
96 <code code="48768-0" codeSystem="2.16.840.1.113883.6.1"/>
97 <title>Versicherung</title>
98 <!-- Versicherung/Coverage -->
99 <entry>
100 <act classCode="ACT" moodCode="EVN">
101 <templateId/>
102 <id/>
103 <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" />
104 <statusCode code="completed"/>
105 <entryRelationship typeCode="COMP">
106 <!-- Versicherungspolicy -->
107 <act classCode="ACT" moodCode="EVN">
108 <templateId root="VERSICHERUNG" />
109 <code code="VERSICHERUNG" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
110 <statusCode code="completed"/>
111 <!-- Payer Information -->
112 <performer>
113 <assignedEntity>
114 <id extension="Kassen-ID-47" />
115 <addr>
116 <streetAddressLine>AOK-Weg 1459</streetAddressLine>
117 <postalCode>10111</postalCode>
118 <city>Berlin</city>
119 </addr>
120 <representedOrganization>
121 <name>Versicherung AOK Berlin</name>
122 </representedOrganization>
123 </assignedEntity>
124 </performer>
125 <!-- Guarantor -->
126 <!--
127 <performer modeCode="WRITTEN" />
128 -->
129 <!-- Versicherung -->
130 <participant typeCode="COV">
131 <time>
132 <high value="20181231"/>
133 </time>
134 <participantRole>
135 <!-- Versichertenstatus -->
136 <code code="1"/>
137 </participantRole>
138 </participant>
139 <!-- Versicherter -->
140 <participant typeCode="HLD">
141 <participantRole>
142 <id root="xxxxxxxxx" extension="VNR=4711" />
143 </participantRole>
144 </participant>
145 <entryRelationship typeCode="COMP" >
146 <!-- Person Group Observation -->
147 <observation classCode="OBS" moodCode="EVN" >
148 <templateId root="PRSNGRP" />
149 <code code="PRSNGRP" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
150 <!-- aus S_KBV_PERSONENGRUPPE -->
151 <value xsi:type="CD" code="4" codeSystem="1.2.276.0.76.11.151" displayName="SOZ"/>
152 </observation>
153 </entryRelationship>
154 <entryRelationship typeCode="COMP" >
155 <!-- DMP Observation -->
156 <observation classCode="OBS" moodCode="EVN">
157 <templateId root="DMP" />
158 <code code="DMP" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
159 <!-- aus S_KBV_DMP -->
160 <value xsi:type="CD" code="D" codeSystem="1.2.276.0.76.11.138"/>
161 </observation>
162 </entryRelationship>
163 <entryRelationship typeCode="COMP" >
164 <!-- DMP Observation -->
165 <observation classCode="OBS" moodCode="EVN">
166 <templateId root="ASV" />
167 <code code="ASV" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
168 <!-- aus S_KBV_ASV -->
169 <value xsi:type="CD" code="A" />
170 </observation>
171 </entryRelationship>
172 </act>
173 </entryRelationship>
174 </act>
175 </entry>
176 </section>
177 </component>
178 <!-- AU-Diagnose Section -->
179 <component>
180 <section>
181 <templateId root="xxxxxx"/>
182 <code code="AU-DIAGNOSIS" />
183 <title>AU-begründende Diagnosen</title>
184 <text>Der Patient will einfach nicht arbeiten!</text>
185 <entry>
186 <observation classCode="OBS" moodCode="EVN">
187 <code code="x47"/>
188 <statusCode code="completed"/>
189 </observation>
190 </entry>
191 <entry>
192 <observation classCode="OBS" moodCode="EVN">
193 <code code="x80"/>
194 <statusCode code="completed"/>
195 </observation>
196 </entry>
197 </section>
198 </component>
199 <!-- Findings Section -->
200 <component>
201 <section>
202 <templateId/>
203 <text>
204
205 </text>
206 </section>
207 </component>
208 <!-- Accident/Unfall Section -->
209 <component>
210 <section>
211 <templateId/>
212 <code code="ACCIDENT"/>
213 <title>Unfall</title>
214 <entry>
215 <observation classCode="OBS" moodCode="EVN">
216 <templateId/>
217 <code code="ACCIDENT"/>
218 <statusCode code="completed"/>
219 <effectiveTime/>
220 <!-- aus S_KBV_01_Accident -->
221 <value xsi:type="CD" code="D-ARZT" codeSystem="1.2.276.0.76.3.1.135.8.11.4"/>
222 </observation>
223 </entry>
224 </section>
225 </component>
226 <!-- Treatment Section -->
227 <component>
228 <section>
229 <templateId/>
230 <code code="TREATMENT"/>
231 <title>Einleitung besonderer Maßnahmen</title>
232 <text>
233 keine Ahnung, was sonst noch zu tun ist
234 </text>
235 <!-- Treatment stufenweise Wiedereingliederung -->
236 <entry>
237 <observation classCode="OBS" moodCode="EVN">
238 <code code="EINGLIEDERUNG" />
239 <value xsi:type="BL" value="false"/>
240 </observation>
241 </entry>
242 <!-- Treatment Leistungen med. Reha Observation -->
243 <entry>
244 <observation classCode="OBS" moodCode="EVN">
245 <code code="REHA" />
246 <value xsi:type="BL" value="true"/>
247 </observation>
248 </entry>
249 </section>
250 </component>
251 <!-- Temporary Disablement Section -->
252 <component>
253 <section>
254 <templateId/>
255 <code code="TEMPDISABLE"/>
256 <title>Arbeitsunfähigkeit</title>
257 <entry>
258 <observation classCode="OBS" moodCode="EVN">
259 <code code="X-IATWRK" codeSystem="2.16.840.1.113883.6.1"/>
260 <text>
261 beliebiger Text
262 </text>
263 <statusCode code="completed"/>
264 <effectiveTime>
265 <!-- Zeitraum der Arbeitsunfähigkeit -->
266 <low value="20171018"/>
267 <high value="20171020"/>
268 </effectiveTime>
269 <value xsi:type="PQ" unit="%" value="100" />
270 <performer>
271 <!-- festgestellt am -->
272 <time value="20171019"/>
273 <assignedEntity>
274 <id/>
275 <assignedPerson>
276 <name>Hugo Müller</name>
277 </assignedPerson>
278 </assignedEntity>
279 </performer>
280 </observation>
281 </entry>
282 </section>
283 </component>
284 </structuredBody>
285 </component>
286</ClinicalDocument>
