Id | 1.2.276.0.76.10.4105 | Gültigkeit | gültig ab 2017‑02‑21Es gibt Versionen von Templates mit dieser Id:- FASTfindings vom 2017‑02‑21
- FASTfindings vom 2017‑02‑01
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Status | Entwurf | Versions-Label | |
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Name | FASTfindings | Anzeigename | FAST Befunde |
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Beschreibung | Findings from Focused assessment with ultrasonography for trauma (procedure) |
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Kontext | Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4105 |
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Klassifikation | CDA Entry Level Template |
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Offen/Geschlossen | Offen (auch andere als die definierten Elemente sind erlaubt) |
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Benutzt von / Benutzt | Benutzt von 0 Transactions und 6 Templates, Benutzt 1 Template | Benutzt von | als | Name | Version |
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1.2.276.0.76.10.4097 | Containment | PreHospital Encounter Entry | 2017‑02‑01 | 1.2.276.0.76.10.3069 |  | Präklinik (Episode) | 2017‑01‑10 | 1.2.276.0.76.10.1021 |  | Trauma Summary CDA document (v1) | 2016‑11‑01 | 1.2.276.0.76.10.4136 | Containment | Inpatient Hospital Encounter Detail Observation Organizer | 2017‑02‑01 | 1.2.276.0.76.10.4133 |  | Hospital Care Episode Encounter | 2017‑02‑01 | 1.2.276.0.76.10.3073 |  | Klinik (Episode) | 2017‑01‑10 | Benutzt | als | Name | Version |
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1.2.276.0.76.10.4134 | Containment | FAST Befunde freie Flüssigkeit | DYNAMIC |
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Beziehung | Spezialisierung: Template 2.16.840.1.113883.10.12.303 (2005‑09‑07) |
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Beispiel | FAST Befund, nur narrativ (in section.text) | <observation classCode="OBS" moodCode="EVN"> <templateId root="1.2.276.0.76.10.4105"/> <id root="1.2.276.0.76.4.17.9814184919" extension="ac9eb111-93b0-4c84-8e55-98f2098b7950"/> <code code="X-FAST" codeSystem="2.16.840.1.113883.6.1" displayName="Focused assessment with ultrasonography for trauma"/> <statusCode code="completed"/> <effectiveTime value="20171219"/> <value xsi:type="CE" nullFlavor="OTH"> <originalText> <reference value="#fast"/> </originalText> </value></observation> |
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Beispiel | FAST Befund, codiert als ohne path. Befund, mit zusätzlichem freien Text (in section.text) | <observation classCode="OBS" moodCode="EVN"> <templateId root="1.2.276.0.76.10.4105"/> <id root="1.2.276.0.76.4.17.9814184919" extension="ac9eb111-93b0-4c84-8e55-98f2098b7950"/> <code code="X-FAST" codeSystem="2.16.840.1.113883.6.1" displayName="Focused assessment with ultrasonography for trauma"/> <statusCode code="completed"/> <effectiveTime value="20171219"/> <value xsi:type="CE" code="OPB" codeSystem="1.2.276.0.76.3.1.195.5.51" displayName="ohne path. Befund"> <originalText> <reference value="#fast"/> </originalText> </value></observation> |
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Beispiel | FAST Befund, codiert mit path. Befund und Text (in section.text), freie Flüssigkeit beobachtet | <observation classCode="OBS" moodCode="EVN"> <templateId root="1.2.276.0.76.10.4105"/> <id root="1.2.276.0.76.4.17.9814184919" extension="ac9eb111-93b0-4c84-8e55-98f2098b7950"/> <code code="X-FAST" codeSystem="2.16.840.1.113883.6.1" displayName="Focused assessment with ultrasonography for trauma"/> <statusCode code="completed"/> <effectiveTime value="20171219"/> <value xsi:type="CE" code="PB" codeSystem="1.2.276.0.76.3.1.195.5.51" displayName="path. Befund"> <originalText> <reference value="#fast"/> </originalText> </value> <entryRelationship typeCode="COMP"> <!-- FAST: Freie Flüssigkeit 1.2.276.0.76.10.4134 --> </entryRelationship></observation> |
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Item | DT | Kard | Konf | Beschreibung | Label |
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| | 1 … 1 | | | (FAS...ngs) |  | @classCode
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| | 1 … 1 | F | OBS |  | @moodCode
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| | 1 … 1 | F | EVN |  | hl7:templateId
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| II | 1 … 1 | | | (FAS...ngs) |  |  | @root
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| | 1 … 1 | F | 1.2.276.0.76.10.4105 |  | hl7:id
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| II | 1 … 1 | | | (FAS...ngs) |  | hl7:code
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| CE | 1 … 1 | M | | (FAS...ngs) |  |  | @code
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| CONF | 1 … 1 | F | X-FAST |  |  | @codeSystem
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| 1 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) |  | hl7:text
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| ED | 0 … 1 | | Lediglich reference in den Text der zugehörigen Section | (FAS...ngs) |  |  | hl7:reference
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| URL | 1 … 1 | | | (FAS...ngs) |  | hl7:statusCode
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| CS | 1 … 1 | M | | (FAS...ngs) |  |  | @code
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| CONF | 1 … 1 | F | completed |  | hl7:effectiveTime
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| TS | 0 … 1 | | Zeitpunkt der Untersuchung | (FAS...ngs) | Auswahl | … 1 | | Elemente in der Auswahl:- hl7:value[@nullFlavor]
- hl7:value[@code]
|  |  | hl7:value
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| CE | … 1 | R | Freitexlicher Befund (in section.text), kein Code | (FAS...ngs) |  |  | wo [@nullFlavor] |
| | | | 1 … 1 | F | OTH | | ED | 0 … 1 | R | Lediglich reference in den Text der zugehörigen Section | (FAS...ngs) | | URL | 1 … 1 | | | (FAS...ngs) |  |  | hl7:value
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| CE | … 1 | R | Codierter Befund mit zusätzlichem freien Text (in section.text) | (FAS...ngs) |  |  | wo [@code] |
| | | CONF | Der Wert von @code muss gewählt werden aus dem Value Set 1.2.276.0.76.11.51 Finding situation (DYNAMIC) |
| | ED | 0 … 1 | R | zusätzlicher freier Text, lediglich reference in den Text der zugehörigen Section | (FAS...ngs) | | URL | 1 … 1 | | | (FAS...ngs) |  | hl7:entryRelationship
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| | 0 … 1 | R | FAST: freie Flüssigkeit Beinhaltet 1.2.276.0.76.10.4134 FAST Befunde freie Flüssigkeit (DYNAMIC) | (FAS...ngs) |  | wo [hl7:observation [hl7:code [(@code='X-FASTFF' and @codeSystem='2.16.840.1.113883.6.1')]]] |
| |  |  | @typeCode
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| cs | 1 … 1 | F | COMP |  |  | @contextConductionInd
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| bl | 0 … 1 | F | true |
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