cdaeau:Beispiel
Version vom 18. Dezember 2017, 16:38 Uhr von Foemig (Diskussion | Beiträge)
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="85216-0" codeSystem="2.16.840.1.113883.6.1" displayName="Disability examination note"/>
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 <documentationOf typeCode="DOC">
92 <ServiceEvent classCode="ACT" moodCode="EVN">
93 <code code="xFOLGE_END" codeSystem="1.2.276.0.76.11.456" displayName="Folgebescheinigung AU"/>
94 </ServiceEvent>
95 </documentationOf>
96 <component>
97 <structuredBody>
98 <!-- Versicherung Section -->
99 <component typeCode="COMP" >
100 <section>
101 <templateId root="xxxxxx"/>
102 <code code="48768-0" codeSystem="2.16.840.1.113883.6.1"/>
103 <title>Versicherung</title>
104 <!-- Versicherung/Coverage -->
105 <entry>
106 <act classCode="ACT" moodCode="EVN">
107 <templateId/>
108 <id/>
109 <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" />
110 <statusCode code="completed"/>
111 <entryRelationship typeCode="COMP">
112 <!-- Versicherungspolicy -->
113 <act classCode="ACT" moodCode="EVN">
114 <templateId root="VERSICHERUNG" />
115 <code code="VERSICHERUNG" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
116 <statusCode code="completed"/>
117 <!-- Payer Information -->
118 <performer>
119 <assignedEntity>
120 <id extension="Kassen-ID-47" />
121 <addr>
122 <streetAddressLine>AOK-Weg 1459</streetAddressLine>
123 <postalCode>10111</postalCode>
124 <city>Berlin</city>
125 </addr>
126 <representedOrganization>
127 <name>Versicherung AOK Berlin</name>
128 </representedOrganization>
129 </assignedEntity>
130 </performer>
131 <!-- Guarantor -->
132 <!--
133 <performer modeCode="WRITTEN" />
134 -->
135 <!-- Versicherung -->
136 <participant typeCode="COV">
137 <time>
138 <high value="20181231"/>
139 </time>
140 <participantRole>
141 <!-- Versichertenstatus -->
142 <code code="1"/>
143 </participantRole>
144 </participant>
145 <!-- Versicherter -->
146 <participant typeCode="HLD">
147 <participantRole>
148 <id root="xxxxxxxxx" extension="VNR=4711" />
149 </participantRole>
150 </participant>
151 <entryRelationship typeCode="COMP" >
152 <!-- Person Group Observation -->
153 <observation classCode="OBS" moodCode="EVN" >
154 <templateId root="PRSNGRP" />
155 <code code="PRSNGRP" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
156 <!-- aus S_KBV_PERSONENGRUPPE -->
157 <value xsi:type="CD" code="4" codeSystem="1.2.276.0.76.11.151" displayName="SOZ"/>
158 </observation>
159 </entryRelationship>
160 <entryRelationship typeCode="COMP" >
161 <!-- DMP Observation -->
162 <observation classCode="OBS" moodCode="EVN">
163 <templateId root="DMP" />
164 <code code="DMP" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
165 <!-- aus S_KBV_DMP -->
166 <value xsi:type="CD" code="D" codeSystem="1.2.276.0.76.11.138"/>
167 </observation>
168 </entryRelationship>
169 <entryRelationship typeCode="COMP" >
170 <!-- DMP Observation -->
171 <observation classCode="OBS" moodCode="EVN">
172 <templateId root="ASV" />
173 <code code="ASV" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
174 <!-- aus S_KBV_ASV -->
175 <value xsi:type="CD" code="A" />
176 </observation>
177 </entryRelationship>
178 </act>
179 </entryRelationship>
180 </act>
181 </entry>
182 </section>
183 </component>
184 <!-- AU-Diagnose Section -->
185 <component>
186 <section>
187 <templateId root="xxxxxx"/>
188 <code code="AU-DIAGNOSIS" />
189 <title>AU-begründende Diagnosen</title>
190 <text>Der Patient will einfach nicht arbeiten!</text>
191 <entry>
192 <observation classCode="OBS" moodCode="EVN">
193 <code code="x47"/>
194 <statusCode code="completed"/>
195 </observation>
196 </entry>
197 <entry>
198 <observation classCode="OBS" moodCode="EVN">
199 <code code="x80"/>
200 <statusCode code="completed"/>
201 </observation>
202 </entry>
203 </section>
204 </component>
205 <!-- Findings Section -->
206 <component>
207 <section>
208 <templateId/>
209 <text>
210
211 </text>
212 </section>
213 </component>
214 <!-- Accident/Unfall Section -->
215 <component>
216 <section>
217 <templateId/>
218 <code code="ACCIDENT"/>
219 <title>Unfall</title>
220 <entry>
221 <observation classCode="OBS" moodCode="EVN">
222 <templateId/>
223 <code code="ACCIDENT"/>
224 <statusCode code="completed"/>
225 <effectiveTime/>
226 <!-- aus S_KBV_01_Accident -->
227 <value xsi:type="CD" code="D-ARZT" codeSystem="1.2.276.0.76.3.1.135.8.11.4"/>
228 </observation>
229 </entry>
230 </section>
231 </component>
232 <!-- Treatment Section -->
233 <component>
234 <section>
235 <templateId/>
236 <code code="TREATMENT"/>
237 <title>Einleitung besonderer Maßnahmen</title>
238 <text>
239 keine Ahnung, was sonst noch zu tun ist
240 </text>
241 <!-- Treatment stufenweise Wiedereingliederung -->
242 <entry>
243 <observation classCode="OBS" moodCode="EVN">
244 <code code="EINGLIEDERUNG" />
245 <value xsi:type="BL" value="false"/>
246 </observation>
247 </entry>
248 <!-- Treatment Leistungen med. Reha Observation -->
249 <entry>
250 <observation classCode="OBS" moodCode="EVN">
251 <code code="REHA" />
252 <value xsi:type="BL" value="true"/>
253 </observation>
254 </entry>
255 </section>
256 </component>
257 <!-- Temporary Disablement Section -->
258 <component>
259 <section>
260 <templateId/>
261 <code code="TEMPDISABLE"/>
262 <title>Arbeitsunfähigkeit</title>
263 <entry>
264 <observation classCode="OBS" moodCode="EVN">
265 <code code="X-IATWRK" codeSystem="2.16.840.1.113883.6.1">
266 <qualifier>
267 <!-- auf für nach der 7. Woche -->
268 <name code="x7AU"/>
269 <value code="x7AU"/>
270 </qualifier>
271 </code>
272 <text>
273 beliebiger Text
274 </text>
275 <statusCode code="completed"/>
276 <effectiveTime>
277 <!-- Zeitraum der Arbeitsunfähigkeit -->
278 <low value="20171018"/>
279 <high value="20171020"/>
280 </effectiveTime>
281 <value xsi:type="PQ" unit="%" value="100" />
282 <performer>
283 <!-- festgestellt am -->
284 <time value="20171019"/>
285 <assignedEntity>
286 <id/>
287 <assignedPerson>
288 <name>Hugo Müller</name>
289 </assignedPerson>
290 </assignedEntity>
291 </performer>
292 </observation>
293 </entry>
294 </section>
295 </component>
296 </structuredBody>
297 </component>
298</ClinicalDocument>
