1.2.276.0.76.10.4075/static-2015-12-06T000000

Aus Hl7wiki
Version vom 25. Juli 2018, 10:23 Uhr von ADbot (Diskussion | Beiträge) (Automated ADBot page content)
Wechseln zu: Navigation, Suche
Id1.2.276.0.76.10.4075Gültigkeit2015‑12‑06
Andere Versionen mit dieser Id:
    StatusKyellow.png EntwurfVersions-Label
    NameProblemObservationAnzeigenameProblem Observation
    Beschreibung
    EN-US.png This template reflects a discrete observation about a patient's problem. Because it is a discrete observation, it will have a statusCode of "completed". The effectiveTime, also referred to as the “biologically relevant time” is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of heart attack that occurred five years ago, the effectiveTime is five years ago. The effectiveTime of the Problem Observation is the definitive indication of whether or not the underlying condition is resolved. If the problem is known to be resolved, then an effectiveTime/high would be present. If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK".
    KontextElternknoten des Template-Element mit Id 1.2.276.0.76.10.4075
    KlassifikationCDA Entry Level Template
    Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
    Benutzt von / Benutzt
    Benutzt von 0 Transactions und 3 Templates, Benutzt 6 Templates
    Benutzt von als NameVersion
    1.2.276.0.76.10.4074ContainmentKyellow.png Problem Concern Act2015‑12‑06
    1.2.276.0.76.10.3023Link.pngKyellow.png Frühere Erkrankungen2017‑04‑09
    1.2.276.0.76.10.3079Link.pngKyellow.png Gesundheitsprobleme2017‑03‑01
    Benutzt als NameVersion
    1.2.276.0.76.10.90025InklusionKyellow.png Author (Body)DYNAMIC
    1.2.276.0.76.10.4077ContainmentKyellow.png Alter BeobachtungDYNAMIC
    1.2.276.0.76.10.4078ContainmentKyellow.png Prognose ObservationDYNAMIC
    1.2.276.0.76.10.4076ContainmentKyellow.png Priorität PräferenzDYNAMIC
    1.2.276.0.76.10.4093ContainmentKyellow.png Manifestation ObservationDYNAMIC
    1.2.276.0.76.10.4094ContainmentKyellow.png Etiology ObservationDYNAMIC
    BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
    Adaptation: Template 2.16.840.1.113883.10.20.22.4.4 (2015‑08‑01)
    Beispiel
    Beispiel
    <observation classCode="OBS" moodCode="EVN">
      <!-- Problem Observation -->
      <templateId root="1.2.276.0.76.10.4075"/>  <id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>  <code code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis"/>  <!-- The statusCode reflects the status of the observation itself -->
      <statusCode code="completed"/>  <effectiveTime>
        <!-- Das low Element gibt das Datum an, seit wann der Patient dieses Problem hat -->
        <low value="20130703"/>    <!-- Das high Element gibt das Datum an, seit wann der Patient dieses Problem nicht mehr hat -->
        <high value="20130721"/>  </effectiveTime>      <!-- Im value Element wird das Problem angegeben. Dies kann ein ICD 10 Code oder ein anderer Code sein. -->
      <value xsi:type="CD" code="J11.1" codeSystem="1.2.276.0.76.5.430" displayName="Grippe mit sonstigen Manifestationen an den Atemwegen, Viren nicht nachgewiesen"/>  <author typeCode="AUT">
        <!-- optional: Autor des Problem -->
      </author>    </observation>
    ItemDTKardKonfBeschreibungLabel
    hl7:observation
    		(Pro...ion)
    Treetree.png@classCode
    		cs1 … 1FOBS
    Treetree.png@moodCode
    		cs1 … 1FEVN
    Treetree.png@negationInd
    		bl0 … 1 
    Treetree.pnghl7:templateId
    		1 … 1M(Pro...ion)
    Treeblank.pngTreetree.png@root
    		uid1 … 1F1.2.276.0.76.10.4075
    Treetree.pnghl7:id
    		1 … *(Pro...ion)
    Treetree.pnghl7:code
    		1 … 1M(Pro...ion)
     CONF
    Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.3.88.12.3221.7.2 Problem Type (DYNAMIC)
    Treetree.pnghl7:statusCode
    		1 … 1M(Pro...ion)
    Treeblank.pngTreetree.png@code
    		CONF1 … 1Fcompleted
    Treetree.pnghl7:effectiveTime
    		1 … 1M
    EN-US.png If the problem is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'. Therefore, the existence of an high element within a problem does indicate that the problem has been resolved.
    		(Pro...ion)
    Treeblank.pngTreetree.pnghl7:low
    		1 … 1MDas low Element gibt das Datum an, seit wann der Patient diese Problem hat(Pro...ion)
    Treeblank.pngTreetree.pnghl7:high
    		0 … 1Das high Element gibt das Datum an, seit wann der Patient diese Problem nicht mehr hat(Pro...ion)
    Treetree.pnghl7:value
    		CD1 … 1R(Pro...ion)
     CONF
    muss aus der Konzeptdomäne "Problemcodes" gewählt werden
    Treeblank.pngTreetree.pnghl7:qualifier
    		0 … *
    EN-US.png This value MAY contain zero or more [0..*] qualifier (CONF:1198-31870).

    The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML.
    		(Pro...ion)
    Treeblank.pngTreetree.pnghl7:translation
    		0 … *(Pro...ion)
    Treeblank.pngTreeblank.pngTreetree.png@code
    		0 … 1 
    EN-US.png MAY contain zero or one [0..1] @code (CodeSystem: ICD10CM urn:oid:2.16.840.1.113883.6.90 STATIC) (CONF:1198-16750).
    Treetree.pnghl7:author
    		0 … *R(Pro...ion)
    Eingefügt von 1.2.276.0.76.10.90025 Author (Body) (DYNAMIC)
    Treeblank.pngTreetree.png@typeCode
    		0 … 1FAUT
    Treeblank.pngTreetree.png@context​Control​Code
    		0 … 1FOP
    Treeblank.pngTreetree.pnghl7:functionCode
    		CE0 … 1(Pro...ion)
     CONF
    Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
    Treeblank.pngTreetree.pnghl7:time
    		TS1 … 1R(Pro...ion)
    Treeblank.pngTreetree.pnghl7:assignedAuthor
    		1 … 1R(Pro...ion)
    Treeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FASSIGNED
    Treeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II1 … *R(Pro...ion)
    Treeblank.pngTreeblank.pngTreetree.pnghl7:code
    		CE0 … 1(Pro...ion)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
    		CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
    Treeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … *(Pro...ion)
    Treeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … *(Pro...ion)
    Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
    		0 … 1(Pro...ion)
    Eingefügt von 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FPSN
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		PN1 … 1M(Pro...ion)
    Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
    		0 … 1(Pro...ion)
    Eingefügt von 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
    		0 … 1FORG
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
    		0 … 1FINSTANCE
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
    		II0 … *(Pro...ion)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
    		ON1 … 1M(Pro...ion)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
    		TEL0 … *(Pro...ion)
    Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
    		AD0 … 1(Pro...ion)
    Treetree.pnghl7:entryRelationship
    		0 … 1Alter des Patienten
    Beinhaltet 1.2.276.0.76.10.4077 Alter Beobachtung (DYNAMIC)    		(Pro...ion)
    Treeblank.png wo [hl7:observation [hl7:code [(@code = '30525-0' and @codeSystem = '2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FSUBJ
    Treeblank.pngTreetree.png@inversionInd
    		bl1 … 1Ftrue
    Treetree.pnghl7:entryRelationship
    		0 … 1Prognose des Problems
    Beinhaltet 1.2.276.0.76.10.4078 Prognose Observation (DYNAMIC)    		(Pro...ion)
    Treeblank.png wo [hl7:observation [hl7:code [(@code = '75328-5' and @codeSystem = '2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FREFR
    Treetree.pnghl7:entryRelationship
    		0 … *Schweregrad des Problems laut Einschätzung des Gesundheitsdienstleisters
    Beinhaltet 1.2.276.0.76.10.4076 Priorität Präferenz (DYNAMIC)    		(Pro...ion)
    Treeblank.png wo [hl7:observation [hl7:code [(@code = '77303-6' and @codeSystem = '2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FREFR
    Treetree.pnghl7:entryRelationship
    		0 … *Manifestations-Beobachtung
    Beinhaltet 1.2.276.0.76.10.4093 Manifestation Observation (DYNAMIC)    		(Pro...ion)
    Treeblank.png wo [hl7:observation [hl7:code [(@code = '75328-5' and @codeSystem = '2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FMFST
    Treetree.pnghl7:entryRelationship
    		0 … *Ätiologie-Beobachtung
    Beinhaltet 1.2.276.0.76.10.4094 Etiology Observation (DYNAMIC)    		(Pro...ion)
    Treeblank.png wo [hl7:observation [hl7:code [(@code = '75328-5' and @codeSystem = '2.16.840.1.113883.6.1')]]]
    Treeblank.pngTreetree.png@typeCode
    		cs1 … 1FCAUS
    Abgerufen von „https://wiki.hl7.de/index.php?title=1.2.276.0.76.10.4075/static-2015-12-06T000000&oldid=52022“