1.2.276.0.76.10.4048/static-2016-06-22T000000: Unterschied zwischen den Versionen

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<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.276.0.76.10.4048</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;"> gültig ab 2016‑06‑22<p></p>Es gibt Versionen von Templates mit dieser Id:<ul><li>Problemconcernacteddiagnoses vom 2016‑06‑22</li><li>Problemconcernacteddiagnoses vom 2015‑03‑03</li></ul></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kgreen.png|14px]] Aktiv</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;"></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">Problemconcernacteddiagnoses</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Problem Concern Act (Abschlussdiagnosen)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beschreibung</th><td style="text-align: left;" colspan="3">Sammelkontainer für Beschwerden, Symptome, Diagnose, Probleme etc., hier: Abschlussdiagnosen ggf. mit ICD10-Kodes</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Kontext</th><td style="text-align: left;" colspan="3">Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4048</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Entry Level Template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Offen/Geschlossen</th><td style="text-align: left;" colspan="3">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Benutzt von / Benutzt</th><td style="text-align: left;" colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt von 0 Transactions und 4 Templates, Benutzt 1 Template</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Benutzt von</th><th style="width: 1%; text-align: left;"> als </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.2.276.0.76.10.3055</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Abschlussdiagnosen (Basis)</td><td style="text-align: left;">2016‑06‑22</td></tr><tr><td style="text-align: left;">1.2.276.0.76.10.1019</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Emergency medicine Note CDA document (v2)</td><td style="text-align: left;">2016‑06‑01</td></tr><tr><td style="text-align: left;">1.2.276.0.76.10.3077</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Abschlussdiagnosen (Trauma)</td><td style="text-align: left;">2017‑01‑10</td></tr><tr><td style="text-align: left;">1.2.276.0.76.10.1021</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Trauma Summary CDA document (v1)</td><td style="text-align: left;">2016‑11‑01</td></tr><tr><th style="width: 20%; text-align: left;">Benutzt</th><th style="width: 1%; text-align: left;"> als </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.2.276.0.76.10.4049</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Problem Observation (Abschlussdiagnose)</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beziehung</th><td style="text-align: left;" colspan="3">Spezialisierung: Template 2.16.840.1.113883.10.12.301 <i> </i> (2005‑09‑07)<br />Adaptation: Template 2.16.840.1.113883.10.20.22.4.3 <i> </i> (DYNAMIC)<br />Adaptation: Template 1.2.276.0.76.10.4002 <i> </i> (DYNAMIC)</td></tr><tr class="explabel" style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelblue"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Beispiel</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">act</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">ACT</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.4048</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.4.17.9814184919</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">afe65ff8-ed4b-4f7e-82c3-e98e58b45dbb</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">CONC</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.5.6</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Concern</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">active</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20150304</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">SUBJ</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">sequenceNumber</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Problem observation template --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">act</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Kard</th><th style="width: 2em; text-align: left;">Konf</th><th style="text-align: left;">Beschreibung</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:act<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Pro…ses)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">ACT</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@moodCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Pro…ses)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.276.0.76.10.4048</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Pro…ses)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:code<br /></strong></tt></td></tr></table></td><td><strong>CE</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Pro…ses)</span></td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@code<br /></strong></tt></td></tr></table></td><td rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">CONC</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.5.6</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:statusCode<br /></strong></tt></td></tr></table></td><td><strong>CS</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Pro…ses)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.15933 <i>ActStatus </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:effectiveTime<br /></strong></tt></td></tr></table></td><td><strong>IVL_TS</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Pro…ses)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:low<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Pro…ses)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:high<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Pro…ses)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entryRelationship<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>Abschlussdiagnose, als Text und/oder ICD10-kodiert<br />Beinhaltet 1.2.276.0.76.10.4049 <i>Problem Observation (Abschlussdiagnose)</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Pro…ses)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo  <i> [hl7:observation [hl7:code [(@code='75324-4' and @codeSystem='2.16.840.1.113883.6.1')]]]</i></td></tr></table></td><td></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SUBJ</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:sequenceNumber<br /></strong></tt></td></tr></table></td><td><strong>INT.POS</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Sequenznummer wird weggelassen bei ungeordneten/gleichwertigen Diagnosen ohne führende Diagnose;<br />                            zur Andeutung einer führenden Diagnose wird die Sequenznummer "1" verwendet (maximal einmal), alle weiteren Diagnosen sollten dann eine Sequenznummern &gt; 1 haben oder keine Sequenznummern aufweisen.</td><td style="background-color: #FFEEEE;"><span title="">(Pro…ses)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2">[[File:Kred.png|14px]] error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">count(hl7:entryRelationship[hl7:sequenceNumber='1'])&lt;=1</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">Sequenznummer = 1 (führende Abschlussdiagnose) kann höchstens einmal vergeben werden</span></td><td style="background-color: white;"> </td></tr></table></td></tr></table>
+
<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.276.0.76.10.4048</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;"> gültig ab 2016‑06‑22<p></p>Es gibt Versionen von Templates mit dieser Id:<ul><li>Problemconcernacteddiagnoses vom 2016‑06‑22</li><li>Problemconcernacteddiagnoses vom 2015‑03‑03</li></ul></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kgreen.png|14px]] Aktiv</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;"></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">Problemconcernacteddiagnoses</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Problem Concern Act (Abschlussdiagnosen)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beschreibung</th><td style="text-align: left;" colspan="3">Sammelkontainer für Beschwerden, Symptome, Diagnose, Probleme etc., hier: Abschlussdiagnosen ggf. mit ICD10-Kodes</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Kontext</th><td style="text-align: left;" colspan="3">Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4048</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Entry Level Template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Offen/Geschlossen</th><td style="text-align: left;" colspan="3">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Benutzt von / Benutzt</th><td style="text-align: left;" colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt von 0 Transactions und 4 Templates, Benutzt 1 Template</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Benutzt von</th><th style="width: 1%; text-align: left;"> als </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.2.276.0.76.10.3055</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Abschlussdiagnosen (Basis)</td><td style="text-align: left;">2016‑06‑22</td></tr><tr><td style="text-align: left;">1.2.276.0.76.10.1019</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Emergency medicine Note CDA document (v2)</td><td style="text-align: left;">2016‑06‑01</td></tr><tr><td style="text-align: left;">1.2.276.0.76.10.3077</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Abschlussdiagnosen (Trauma)</td><td style="text-align: left;">2017‑01‑10</td></tr><tr><td style="text-align: left;">1.2.276.0.76.10.1021</td><td style="text-align: left;">[[File:Link.png|14px]]</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Trauma Summary CDA document (v1)</td><td style="text-align: left;">2016‑11‑01</td></tr><tr><th style="width: 20%; text-align: left;">Benutzt</th><th style="width: 1%; text-align: left;"> als </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.2.276.0.76.10.4049</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Problem Observation (Abschlussdiagnose)</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beziehung</th><td style="text-align: left;" colspan="3">Spezialisierung: Template 2.16.840.1.113883.10.12.301 <i> </i> (2005‑09‑07)<br />Adaptation: Template 2.16.840.1.113883.10.20.22.4.3 <i> </i> (DYNAMIC)<br />Adaptation: Template 1.2.276.0.76.10.4002 <i> </i> (DYNAMIC)</td></tr><tr class="explabel " style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelblue"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Beispiel</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">act</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">ACT</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.10.4048</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.276.0.76.4.17.9814184919</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">afe65ff8-ed4b-4f7e-82c3-e98e58b45dbb</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">CONC</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.5.6</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Concern</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">active</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20150304</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">SUBJ</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">sequenceNumber</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">    <span style="color:green">&lt;!-- Problem observation template --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">act</span><span class="ppsign">&gt;</span></span></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Kard</th><th style="width: 2em; text-align: left;">Konf</th><th style="text-align: left;">Beschreibung</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:act<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Pro...ses)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">ACT</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@moodCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:templateId<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Pro...ses)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@root<br /></strong></tt></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.276.0.76.10.4048</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:id<br /></strong></tt></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Pro...ses)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:code<br /></strong></tt></td></tr></table></td><td><strong>CE</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Pro...ses)</span></td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@code<br /></strong></tt></td></tr></table></td><td rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">CONC</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.5.6 (ActClass)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:statusCode<br /></strong></tt></td></tr></table></td><td><strong>CS</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Pro...ses)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.15933 <i>ActStatus </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:effectiveTime<br /></strong></tt></td></tr></table></td><td><strong>IVL_TS</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Pro...ses)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:low<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Pro...ses)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:high<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(Pro...ses)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entryRelationship<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … *</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>Abschlussdiagnose, als Text und/oder ICD10-kodiert<br />Beinhaltet 1.2.276.0.76.10.4049 <i>Problem Observation (Abschlussdiagnose)</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Pro...ses)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo  <i> [@typeCode='SUBJ'] [hl7:observation [hl7:templateId &#8203;[@root&#8203;=&#8203;'1.2.276.0.76.10.4049']]]</i></td></tr></table></td><td></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SUBJ</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:sequenceNumber<br /></strong></tt></td></tr></table></td><td><strong>INT.POS</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Sequenznummer wird weggelassen bei ungeordneten/gleichwertigen Diagnosen ohne führende Diagnose;<br />                            zur Andeutung einer führenden Diagnose wird die Sequenznummer "1" verwendet (maximal einmal), alle weiteren Diagnosen sollten dann eine Sequenznummern &gt; 1 haben oder keine Sequenznummern aufweisen.</td><td style="background-color: #FFEEEE;"><span title="">(Pro...ses)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2">[[File:Kred.png|14px]] error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">count(hl7:entryRelationship[hl7:sequenceNumber='1'])&lt;=1</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2"><span class="pptext">Sequenznummer = 1 (führende Abschlussdiagnose) kann höchstens einmal vergeben werden</span></td><td style="background-color: white;"> </td></tr></table></td></tr></table>

Version vom 17. Dezember 2017, 13:16 Uhr

Id1.2.276.0.76.10.4048Gültigkeit gültig ab 2016‑06‑22

Es gibt Versionen von Templates mit dieser Id:
  • Problemconcernacteddiagnoses vom 2016‑06‑22
  • Problemconcernacteddiagnoses vom 2015‑03‑03
StatusKgreen.png AktivVersions-Label
NameProblemconcernacteddiagnosesAnzeigenameProblem Concern Act (Abschlussdiagnosen)
BeschreibungSammelkontainer für Beschwerden, Symptome, Diagnose, Probleme etc., hier: Abschlussdiagnosen ggf. mit ICD10-Kodes
KontextElternknoten des Template-Element mit Id 1.2.276.0.76.10.4048
KlassifikationCDA Entry Level Template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Benutzt von / Benutzt
Benutzt von 0 Transactions und 4 Templates, Benutzt 1 Template
Benutzt von als NameVersion
1.2.276.0.76.10.3055ContainmentKgreen.png Abschlussdiagnosen (Basis)2016‑06‑22
1.2.276.0.76.10.1019Link.pngKgreen.png Emergency medicine Note CDA document (v2)2016‑06‑01
1.2.276.0.76.10.3077ContainmentKyellow.png Abschlussdiagnosen (Trauma)2017‑01‑10
1.2.276.0.76.10.1021Link.pngKyellow.png Trauma Summary CDA document (v1)2016‑11‑01
Benutzt als NameVersion
1.2.276.0.76.10.4049ContainmentKyellow.png Problem Observation (Abschlussdiagnose)DYNAMIC
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.301 (2005‑09‑07)
Adaptation: Template 2.16.840.1.113883.10.20.22.4.3 (DYNAMIC)
Adaptation: Template 1.2.276.0.76.10.4002 (DYNAMIC)
Beispiel
Beispiel
<act classCode="ACT" moodCode="EVN">
  <templateId root="1.2.276.0.76.10.4048"/>  <id root="1.2.276.0.76.4.17.9814184919" extension="afe65ff8-ed4b-4f7e-82c3-e98e58b45dbb"/>  <code code="CONC" codeSystem="2.16.840.1.113883.5.6" displayName="Concern"/>  <statusCode code="active"/>  <effectiveTime>
    <low value="20150304"/>  </effectiveTime>
  <entryRelationship typeCode="SUBJ">
    <sequenceNumber value="1"/>    <!-- Problem observation template -->
  </entryRelationship>
</act>
ItemDTKardKonfBeschreibungLabel
hl7:act
(Pro...ses)
Treetree.png@classCode
cs1 … 1FACT
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1(Pro...ses)
Treeblank.pngTreetree.png@root
uid1 … 1F1.2.276.0.76.10.4048
Treetree.pnghl7:id
II1 … *M(Pro...ses)
Treetree.pnghl7:code
CE1 … 1M(Pro...ses)
Treeblank.pngTreetree.png@code
CONF1 … 1FCONC
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.5.6 (ActClass)
Treetree.pnghl7:statusCode
CS1 … 1M(Pro...ses)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1R(Pro...ses)
Treeblank.pngTreetree.pnghl7:low
1 … 1R(Pro...ses)
Treeblank.pngTreetree.pnghl7:high
0 … 1R(Pro...ses)
Treetree.pnghl7:entryRelationship
1 … *MAbschlussdiagnose, als Text und/oder ICD10-kodiert
Beinhaltet 1.2.276.0.76.10.4049 Problem Observation (Abschlussdiagnose) (DYNAMIC)
(Pro...ses)
Treeblank.png wo [@typeCode='SUBJ'] [hl7:observation [hl7:templateId ​[@root​=​'1.2.276.0.76.10.4049']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSUBJ
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT.POS0 … *Sequenznummer wird weggelassen bei ungeordneten/gleichwertigen Diagnosen ohne führende Diagnose;
zur Andeutung einer führenden Diagnose wird die Sequenznummer "1" verwendet (maximal einmal), alle weiteren Diagnosen sollten dann eine Sequenznummern > 1 haben oder keine Sequenznummern aufweisen.
(Pro...ses)
 Schematron assertroleKred.png error 
 testcount(hl7:entryRelationship[hl7:sequenceNumber='1'])<=1 
 MeldungSequenznummer = 1 (führende Abschlussdiagnose) kann höchstens einmal vergeben werden