Item | DT | Kard | Konf | Beschreibung | Label |
---|
| | | | | (Tra...ent) |
Eingefügt | 1 … 1 | M | von 1.2.276.0.76.10.90002 CDA realmCode (DYNAMIC) |
| hl7:realmCode
|
| CS | 1 … 1 | M | | CDAr...Code |
| | @code
|
| cs | 1 … 1 | R | |
| CONF | |
| Beispiel | <realmCode code="DE"/> |
Eingefügt | 1 … 1 | M | von 1.2.276.0.76.10.90003 CDA typeId (DYNAMIC) |
| hl7:typeId
|
| II | 1 … 1 | M | | CDAtypeId |
| | @extension
|
| | 1 … 1 | F | POCD_HD000040 |
| | @root
|
| | 1 … 1 | F | 2.16.840.1.113883.1.3 |
| hl7:templateId
|
| II | 1 … 1 | M | | (Tra...ent) |
| | @root
|
| | 1 … 1 | F | 1.2.276.0.76.10.1021 |
Eingefügt | 1 … 1 | M | von 1.2.276.0.76.10.90004 CDA id (DYNAMIC) |
| hl7:id
|
| II | 1 … 1 | M | | (Tra...ent) |
| hl7:code
|
| CE | 1 … 1 | M | | (Tra...ent) |
| | @code
|
| CONF | 1 … 1 | F | 74198-3 |
| | @codeSystem
|
| 1 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) |
Eingefügt | 0 … 1 | | von 1.2.276.0.76.10.90005 CDA title (DYNAMIC) |
| Beispiel | <title>Trauma Summary registry report 2016-09-08 12:34:56</title> |
| hl7:title
|
| ST | 0 … 1 | | | (Tra...ent) |
Eingefügt | 1 … 1 | M | von 1.2.276.0.76.10.90006 CDA effectiveTime (DYNAMIC) |
| hl7:effectiveTime
|
| TS.DATETIME.MIN | 1 … 1 | M | | (Tra...ent) |
Eingefügt | | | von 1.2.276.0.76.10.90007 CDA confidentialityCode (DYNAMIC) |
| hl7:confidentialityCode
|
| CE | 1 … 1 | M | | (Tra...ent) |
| CONF | Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.16926 HL7 BasicConfidentialityKind (DYNAMIC) |
|
Eingefügt | | | von 1.2.276.0.76.10.90008 CDA languageCode (DYNAMIC) |
| hl7:languageCode
|
| CS.LANG | 1 … 1 | M | | (Tra...ent) |
Eingefügt | | | von 1.2.276.0.76.10.90009 CDA setId and versionNumber (DYNAMIC) |
| hl7:setId
|
| II | 1 … 1 | M | | (Tra...ent) |
| hl7:versionNumber
|
| INT.POS | 1 … 1 | M | | (Tra...ent) |
Eingefügt | 1 … 1 | M | von 1.2.276.0.76.10.2032 CDA recordTarget (nnar) (DYNAMIC) |
| hl7:recordTarget
|
| | 1 … 1 | M | | (Tra...ent) |
| | @typeCode
|
| | 0 … 1 | F | RCT |
| | @contextControlCode
|
| | 0 … 1 | F | OP |
| | hl7:patientRole
|
| | 1 … 1 | | | (Tra...ent) |
| | 0 … 1 | F | PAT |
Eingefügt | 1 … 1 | R | von 1.2.276.0.76.10.90024 Patientenidentifikation (DYNAMIC) |
| II | 1 … 1 | R | | (Tra...ent) |
| Beispiel | eGK Nummer als Patientenidentifikation <id extension="A123456789" root="1.2.276.0.76.4.8"/> |
| AD | 0 … 1 | | | (Tra...ent) |
| TEL | 0 … * | | | (Tra...ent) |
| | 1 … 1 | R | | (Tra...ent) |
| | 0 … 1 | F | PSN |
| | 0 … 1 | F | INSTANCE |
| Beispiel | <patient classCode="PSN" determinerCode="INSTANCE"> <name> <!-- ... --> </name> <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/> <birthTime value="19620219"/></patient> |
| PN | 1 … * | R | | (Tra...ent) |
| | | | hl7:administrativeGenderCode
|
| CE | 1 … 1 | R | | (Tra...ent) |
| CONF | Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.1 AdministrativeGender (DYNAMIC) |
|
| TS | 1 … 1 | R | | (Tra...ent) |
Eingefügt | 1 … * | M | von 1.2.276.0.76.10.2033 CDA author (DYNAMIC) |
| hl7:author
|
| | 1 … * | M | | (Tra...ent) |
| | @typeCode
|
| | 0 … 1 | F | AUT |
| | hl7:time
|
| TS.DATE.MIN | 1 … 1 | M | | (Tra...ent) |
| | hl7:assignedAuthor
|
| | 1 … 1 | M | | (Tra...ent) |
| | 0 … 1 | F | ASSIGNED |
| II | 1 … 1 | R | | (Tra...ent) |
| | 0 … 1 | | | (Tra...ent) |
Eingefügt | | | von 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC) |
| | 0 … 1 | F | PSN |
| | 0 … 1 | F | INSTANCE |
| PN | 1 … 1 | M | | (Tra...ent) |
| | | hl7:representedOrganization
|
| | 0 … 1 | | | (Tra...ent) |
Eingefügt | | | von 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC) |
| | 0 … 1 | F | ORG |
| | 0 … 1 | F | INSTANCE |
| II | 0 … * | | | (Tra...ent) |
| ON | 1 … 1 | M | | (Tra...ent) |
| TEL | 0 … * | | | (Tra...ent) |
| AD | 0 … 1 | | | (Tra...ent) |
Eingefügt | 1 … 1 | M | von 1.2.276.0.76.10.2034 CDA custodian (DYNAMIC) |
| hl7:custodian
|
| | 1 … 1 | M | | (Tra...ent) |
| | @typeCode
|
| | 0 … 1 | F | CST |
| | hl7:assignedCustodian
|
| | 1 … 1 | M | | (Tra...ent) |
| | 0 … 1 | F | ASSIGNED |
| | | hl7:representedCustodianOrganization
|
| | 0 … 1 | | | (Tra...ent) |
Eingefügt | | | von 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC) |
| | 0 … 1 | F | ORG |
| | 0 … 1 | F | INSTANCE |
| II | 0 … * | | | (Tra...ent) |
| ON | 1 … 1 | M | | (Tra...ent) |
| TEL | 0 … * | | | (Tra...ent) |
| AD | 0 … 1 | | | (Tra...ent) |
Eingefügt | 0 … * | | von 1.2.276.0.76.10.2005 CDA informationRecipient (DYNAMIC) |
| hl7:informationRecipient
|
| | 0 … * | | | (Tra...ent) |
| | @typeCode
|
| cs | 0 … 1 | | Typ des Empfängers: im @typeCode der Participation kann angegeben werden, ob es sich um einen primären Empfänger handelt (default) oder einen sekundären Empfänger („CC Kopie"). Der typeCode PRCP ist der default. |
| CONF | @typeCode muss "PRCP" sein | oder | @typeCode muss "TRC" sein |
|
| | hl7:intendedRecipient
|
| | 1 … 1 | M | | (Tra...ent) |
| II | 1 … * | R | | (Tra...ent) |
Auswahl | 1 … * | | Wenn der beabsichtigte Empfänger eine Person ist, dann wird dies durch die Anwesenheit der Person Klasse mit oder ohne zugehörige Organisation spezifiziert. Wenn der beabsichtigte Empfänger eine Organisation ist, wird nur die Organisation angegeben, die Person fehlt. Elemente in der Auswahl:- hl7:informationRecipient
- hl7:receivedOrganization
|
| | | | hl7:informationRecipient
|
| | 0 … 1 | | | (Tra...ent) |
Eingefügt | | | von 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC) |
| | 0 … 1 | F | PSN |
| | 0 … 1 | F | INSTANCE |
| PN | 1 … 1 | M | | (Tra...ent) |
| | | | hl7:receivedOrganization
|
| | 0 … 1 | | | (Tra...ent) |
Eingefügt | | | von 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC) |
| | 0 … 1 | F | ORG |
| | 0 … 1 | F | INSTANCE |
| II | 0 … * | | | (Tra...ent) |
| ON | 1 … 1 | M | | (Tra...ent) |
| TEL | 0 … * | | | (Tra...ent) |
| AD | 0 … 1 | | | (Tra...ent) |
Eingefügt | 1 … 1 | M | von 1.2.276.0.76.10.2042 Dienstleistung/Behandlung (Trauma) (DYNAMIC) |
| hl7:documentationOf
|
| | 1 … 1 | M | | (Tra...ent) |
| | @typeCode
|
| | 1 … 1 | F | DOC |
| | hl7:serviceEvent
|
| | 1 … 1 | R | | (Tra...ent) |
| | 1 … 1 | F | ACT |
| | 1 … 1 | F | EVN |
| | 0 … 1 | R | | (Tra...ent) |
| |
| | 1 … 1 | F | PRF |
| CE | 1 … 1 | M | | (Tra...ent) |
| CONF | 1 … 1 | F | LA18712-2 |
| 1 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) |
| | 1 … 1 | M | | (Tra...ent) |
| | 1 … 1 | F | ASSIGNED |
| Beispiel | <assignedEntity classCode="ASSIGNED"> <id nullFlavor="NA"/> <assignedPerson> <name>Dr. No T. Fall</name> </assignedPerson></assignedEntity> |
| II | 1 … 1 | R | | (Tra...ent) |
| | 1 … 1 | F | NA |
| | 1 … 1 | R | | (Tra...ent) |
| PN | 1 … 1 | R | Name | (Tra...ent) |
| | 0 … * | R | | (Tra...ent) |
| |
| | 1 … 1 | F | SPRF |
| Beispiel | <performer typeCode="SPRF"> <assignedEntity> <id nullFlavor="NA"/> <functionCode code="ANAE" codeSystem="1.2.276.0.76.5.86" displayName="Anästhesist"/> <assignedPerson> <name>Dr. Anasthesia Narkos</name> </assignedPerson> </assignedEntity></performer> |
| CE | 1 … 1 | M | | (Tra...ent) |
| CONF | Der Wert von @code muss gewählt werden aus dem Value Set 1.2.276.0.76.11.86 Notaufnahmeteam (DYNAMIC) |
|
| | 1 … 1 | M | | (Tra...ent) |
| | 1 … 1 | F | ASSIGNED |
| II | 1 … 1 | R | | (Tra...ent) |
| | 1 … 1 | F | NA |
| | 1 … 1 | R | | (Tra...ent) |
| PN | 1 … 1 | R | Name | (Tra...ent) |
| hl7:component
|
| | | | | (Tra...ent) |
| | @typeCode
|
| | 0 … 1 | F | COMP |
| | @contextConductionInd
|
| | 0 … 1 | F | true |
| | hl7:structuredBody
|
| | | | | (Tra...ent) |
| | 0 … 1 | F | DOCBODY |
| | 0 … 1 | F | EVN |
| | 1 … 1 | R | Beinhaltet 1.2.276.0.76.10.3068 Unfallereignis (DYNAMIC) | (Tra...ent) |
| | | wo [hl7:section [hl7:code [(@code='74209-8' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |
| | 1 … 1 | F | COMP |
| | 1 … 1 | F | true |
| | 1 … 1 | R | Beinhaltet 1.2.276.0.76.10.3069 Präklinik (Episode) (DYNAMIC) | (Tra...ent) |
| | | wo [hl7:section [hl7:code [(@code='74207-2' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |
| | 1 … 1 | F | COMP |
| | 1 … 1 | F | true |
| | 1 … 1 | R | Beinhaltet 1.2.276.0.76.10.3072 Körperliche Untersuchung (DYNAMIC) | (Tra...ent) |
| | | wo [hl7:section [hl7:code [(@code='29545-1' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |
| | 1 … 1 | F | COMP |
| | 1 … 1 | F | true |
| | 1 … 1 | R | Beinhaltet 1.2.276.0.76.10.3073 Klinik (Episode) (DYNAMIC) | (Tra...ent) |
| | | wo [hl7:section [hl7:code [(@code='74211-4' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |
| | 1 … 1 | F | COMP |
| | 1 … 1 | F | true |
| | 1 … 1 | R | Beinhaltet 1.2.276.0.76.10.3077 Abschlussdiagnosen (Trauma) (DYNAMIC) | (Tra...ent) |
| | | wo [hl7:section [hl7:code [(@code='78322-5' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |
| | 1 … 1 | F | COMP |
| | 1 … 1 | F | true |