1.2.276.0.76.10.4075/static-2015-12-06T000000: Unterschied zwischen den Versionen

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Version vom 13. September 2018, 20:08 Uhr

<tmp1 xmlns="">Id</tmp1>1.2.276.0.76.10.4075<tmp1 xmlns="">Gültigkeit</tmp1>2015‑12‑06
<tmp1 xmlns="">Status</tmp1>Kyellow.png Entwurf<tmp1 xmlns="">Versions-Label</tmp1>
<tmp1 xmlns="">Name</tmp1>ProblemObservation<tmp1 xmlns="">Anzeigename</tmp1>Problem Observation
<tmp1 xmlns="">Beschreibung</tmp1>
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".
<tmp1 xmlns="">Kontext</tmp1>Elternknoten des Template-Element mit Id 1.2.276.0.76.10.4075
<tmp1 xmlns="">Klassifikation</tmp1>CDA Entry Level Template
<tmp1 xmlns="">Offen/Geschlossen</tmp1><tmp1 xmlns="">Offen (auch andere als die definierten Elemente sind erlaubt)</tmp1>
<tmp1 xmlns="">Benutzt</tmp1>
<tmp1 xmlns="">Benutzt</tmp1> <tmp1 xmlns="">6 Templates</tmp1>
<tmp1 xmlns="">Benutzt</tmp1><tmp1 xmlns=""> als </tmp1><tmp1 xmlns="">Name</tmp1><tmp1 xmlns="">Version</tmp1>
1.2.276.0.76.10.90025<tmp1 xmlns="">Inklusion</tmp1>Kyellow.png Author (Body)<tmp1 xmlns="">DYNAMIC</tmp1>
1.2.276.0.76.10.4077<tmp1 xmlns="">Containment</tmp1>Kyellow.png Alter Beobachtung<tmp1 xmlns="">DYNAMIC</tmp1>
1.2.276.0.76.10.4078<tmp1 xmlns="">Containment</tmp1>Kyellow.png Prognose Observation<tmp1 xmlns="">DYNAMIC</tmp1>
1.2.276.0.76.10.4076<tmp1 xmlns="">Containment</tmp1>Kyellow.png Priorität Präferenz<tmp1 xmlns="">DYNAMIC</tmp1>
1.2.276.0.76.10.4093<tmp1 xmlns="">Containment</tmp1>Kyellow.png Manifestation Observation<tmp1 xmlns="">DYNAMIC</tmp1>
1.2.276.0.76.10.4094<tmp1 xmlns="">Containment</tmp1>Kyellow.png Etiology Observation<tmp1 xmlns="">DYNAMIC</tmp1>
<tmp1 xmlns="">Beziehung</tmp1>Spezialisierung: <tmp1 xmlns="">Template</tmp1> <tmp1 xmlns="">2.16.840.1.113883.10.12.303 (2005‑09‑07)</tmp1>
Adaptation: <tmp1 xmlns="">Template</tmp1> <tmp1 xmlns="">2.16.840.1.113883.10.20.22.4.4 (2015‑08‑01)</tmp1>
<tmp1 xmlns="">Beispiel</tmp1>
<tmp1 xmlns="">Beispiel</tmp1>
<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>
<tmp1 xmlns="">Item</tmp1><tmp1 xmlns="">DT</tmp1><tmp1 xmlns="">Kard</tmp1><tmp1 xmlns="">Konf</tmp1><tmp1 xmlns="">Beschreibung</tmp1><tmp1 xmlns="">Label</tmp1>
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
<tmp1 xmlns="">Der Wert von @code muss gewählt werden aus dem Value Set </tmp1>2.16.840.1.113883.3.88.12.3221.7.2 Problem Type (<tmp1 xmlns="">DYNAMIC</tmp1>)
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
<tmp1 xmlns="">muss aus der Konzeptdomäne "Problemcodes" gewählt werden</tmp1>
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)
<tmp1 xmlns="">Eingefügt</tmp1><tmp1 xmlns=""> von </tmp1>1.2.276.0.76.10.90025 Author (Body) (<tmp1 xmlns="">DYNAMIC</tmp1>)
Treeblank.pngTreetree.png@typeCode
0 … 1FAUT
Treeblank.pngTreetree.png@context​Control​Code
0 … 1FOP
Treeblank.pngTreetree.pnghl7:functionCode
CE0 … 1(Pro...ion)
 CONF
<tmp1 xmlns="">Der Wert von @code muss gewählt werden aus dem Value Set </tmp1>2.16.840.1.113883.1.11.10267 ParticipationFunction (<tmp1 xmlns="">DYNAMIC</tmp1>)
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<tmp1 xmlns=""> (Role Code)</tmp1>
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)
<tmp1 xmlns="">Eingefügt</tmp1><tmp1 xmlns=""> von </tmp1>1.2.276.0.76.10.90010 CDA Person Elements (<tmp1 xmlns="">DYNAMIC</tmp1>)
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)
<tmp1 xmlns="">Eingefügt</tmp1><tmp1 xmlns=""> von </tmp1>1.2.276.0.76.10.90011 CDA Organization Elements (<tmp1 xmlns="">DYNAMIC</tmp1>)
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
<tmp1 xmlns="">Beinhaltet</tmp1> 1.2.276.0.76.10.4077 Alter Beobachtung (<tmp1 xmlns="">DYNAMIC</tmp1>)		(Pro...ion)
Treeblank.png<tmp1 xmlns=""> wo </tmp1> [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
<tmp1 xmlns="">Beinhaltet</tmp1> 1.2.276.0.76.10.4078 Prognose Observation (<tmp1 xmlns="">DYNAMIC</tmp1>)		(Pro...ion)
Treeblank.png<tmp1 xmlns=""> wo </tmp1> [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
<tmp1 xmlns="">Beinhaltet</tmp1> 1.2.276.0.76.10.4076 Priorität Präferenz (<tmp1 xmlns="">DYNAMIC</tmp1>)		(Pro...ion)
Treeblank.png<tmp1 xmlns=""> wo </tmp1> [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
<tmp1 xmlns="">Beinhaltet</tmp1> 1.2.276.0.76.10.4093 Manifestation Observation (<tmp1 xmlns="">DYNAMIC</tmp1>)		(Pro...ion)
Treeblank.png<tmp1 xmlns=""> wo </tmp1> [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
<tmp1 xmlns="">Beinhaltet</tmp1> 1.2.276.0.76.10.4094 Etiology Observation (<tmp1 xmlns="">DYNAMIC</tmp1>)		(Pro...ion)
Treeblank.png<tmp1 xmlns=""> wo </tmp1> [hl7:observation [hl7:code [(@code = '75328-5' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCAUS
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