1.2.276.0.76.3.1.261.1.10.3.6/static-2018-06-04T000000: 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;">1.2.276.0.76.3.1.261.1.10.3.6</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2018‑06‑04</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Entwurf</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;">Dischargediagnosissection2</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Entlassungsdiagnose</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beschreibung</th><td style="text-align: left;" colspan="3">Diagnose, mit der der Patient entlassen wurde<br /></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Section 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;">Assoziiert mit</th><td style="text-align: left;" colspan="3"><table class="treetable" id="assocsTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Assoziiert mit 1 Konzept</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;">Id</th><th style="width: 60%; text-align: left;">Name</th><th style="width: 20%; text-align: left;">Datensatz</th></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;"><span style="color: grey;">dguvbbr-data&#8203;element2-</span>100</td><td style="vertical-align: top;">[[File:Kyellow.png|14px]] Diagnosen/Probleme </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Stationärer Entlassungsbericht  </td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">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 2 Templates</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</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;">1.2.276.0.76.3.1.261.1.10.4.14</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Diagnose Observation</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.276.0.76.3.1.261.1.10.4.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Klassifikation Observation</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 2.16.840.1.113883.10.12.201 <i> </i> (2005‑09‑07)</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 zur Textformatierung der Diagnosen in Form von Tabellen</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">section</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">1.2.276.0.76.3.1.261.1.10.3.2</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">29548-5</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</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">title</span><span class="ppsign">&gt;</span><span class="pptext">Entlassungsdiagnosen</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">table</span> <span class="ppattribute">border</span><span class="ppsign">="</span><span class="ppcontent">1</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">thead</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">th</span><span class="ppsign">&gt;</span><span class="pptext">Diagnose</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">th</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">th</span><span class="ppsign">&gt;</span><span class="pptext">ICD Code</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">th</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">th</span><span class="ppsign">&gt;</span><span class="pptext">Lokalisation</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">th</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">th</span><span class="ppsign">&gt;</span><span class="pptext">Zusatz</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">th</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">thead</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">tbody</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppelement">content</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">diag_1</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Beckenringfraktur</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">content</span><span class="ppsign">&gt;</span></span>          <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span><span class="ppsign">&gt;</span><span class="pptext">S32.8</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span><span class="ppsign">&gt;</span><span class="pptext">--</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span><span class="ppsign">&gt;</span><span class="pptext">G</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">tbody</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">table</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</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:section<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="">(Dis...on2)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-data&#8203;element2-</span>100</td><td style="vertical-align: top;">[[File:Kyellow.png|14px]] Diagnosen/Probleme </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Stationärer Entlassungsbericht  </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: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="">(Dis...on2)</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">1.2.276.0.76.3.1.261.1.10.3.6</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="">(Dis...on2)</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">11535-2</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">2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)</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:title<br /></strong></tt></td></tr></table></td><td><strong>ST</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="">(Dis...on2)</span></td></tr><tr style="vertical-align: top; background-color: #FFEEEE;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4" style="background-color: white;"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Elementinhalt muss "Entlassungsdiagnosen" sein</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:text<br /></strong></tt></td></tr></table></td><td><strong>SD.TEXT</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="">(Dis...on2)</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:entry<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.276.0.76.3.1.261.1.10.4.14 <i>Diagnose Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Dis...on2)</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 = '52534-5' and @codeSystem = '2.16.840.1.113883.6.1') or (@code = '81885-6' and @codeSystem = '2.16.840.1.113883.6.1')]]]</i></td></tr></table></td><td></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">.//hl7:observation[hl7:templateId/@root='1.2.276.0.76.3.1.261.1.10.4.14']/hl7:code[@code=('52534-5','81885-6')]</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">Der Code für die Diagnose-Observation muss 52534-5 LOIINC für die Hauptdiagnose oder 81885-6 LOINC für die Nebendiagnosen sein</span></td><td style="background-color: white;"> </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:entry<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.276.0.76.3.1.261.1.10.4.7 <i>Klassifikation Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Dis...on2)</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 [concat(@code, @codeSystem) = doc('include/voc-1.2.276.0.76.3.1.261.1.11.8-DYNAMIC.xml')//valueSet [1]/conceptList/concept/concat(@code, @codeSystem)]]]</i></td></tr></table></td><td></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4">AO-Klassifikation ausfüllen, wenn die Hauptdiagnose laut ICD-10 eine Fraktur ist<br /><br /><table class="artdecor" style="background: transparent;"><tr><th colspan="1" rowspan="1">Region/Klasse</th><th colspan="1" rowspan="1">Code inkl. aller Unterklassen</th></tr><tr><td colspan="1" rowspan="1">S02.- Fraktur des Schädels und der Gesichtsschädelknochen</td><td colspan="1" rowspan="1">S02.0 - S02.09</td></tr><tr><td colspan="1" rowspan="1">S12.- Fraktur im Bereich des Halses</td><td colspan="1" rowspan="1">S12.0 - S12.9</td></tr><tr><td colspan="1" rowspan="1">S22.- Fraktur der Rippe(n), des Sternums und der Brustwirbelsäule</td><td colspan="1" rowspan="1">S22.0 - S22.9</td></tr><tr><td colspan="1" rowspan="1">S32.- Fraktur der Lendenwirbelsäule und des Beckens</td><td colspan="1" rowspan="1">S32.0 - S32.89</td></tr><tr><td colspan="1" rowspan="1">S42.- Fraktur im Bereich der Schulter und des Oberarmes</td><td colspan="1" rowspan="1">S42.0 - S42.9</td></tr><tr><td colspan="1" rowspan="1">S52.- Fraktur des Unterarmes</td><td colspan="1" rowspan="1">S52.0 - S52.9</td></tr><tr><td colspan="1" rowspan="1">S62.- Fraktur im Bereich des Handgelenkes und der Hand</td><td colspan="1" rowspan="1">S62.0 - S62.8</td></tr><tr><td colspan="1" rowspan="1">S72.- Fraktur des Femurs</td><td colspan="1" rowspan="1">S72.0 - S72.9</td></tr><tr><td colspan="1" rowspan="1">S82.- Fraktur des Unterschenkels, einschließlich des oberen Sprunggelenkes</td><td colspan="1" rowspan="1">S82.0 - S82.9</td></tr><tr><td colspan="1" rowspan="1">S92.- Fraktur des Fußes [ausgenommen oberes Sprunggelenk]</td><td colspan="1" rowspan="1">S92.0 - S92.9</td></tr><tr><td colspan="1" rowspan="1">T02.- Frakturen mit Beteiligung mehrerer Körperregionen</td><td colspan="1" rowspan="1">T02.0 - T02.91</td></tr><tr><td colspan="1" rowspan="1">T08.- Fraktur der Wirbelsäule, Höhe nicht näher bezeichnet</td><td colspan="1" rowspan="1">T08.0 - T08.1</td></tr><tr><td colspan="1" rowspan="1">T10.- Fraktur der oberen Extremität, Höhe nicht näher bezeichnet</td><td colspan="1" rowspan="1">T10.0 - T10.1</td></tr><tr><td colspan="1" rowspan="1">T12.- Fraktur der unteren Extremität, Höhe nicht näher bezeichnet</td><td colspan="1" rowspan="1">T12.0 - T12.1</td></tr><tr><td colspan="1" rowspan="1">T14.- Verletzung an einer nicht näher bezeichneten Körperregion</td><td colspan="1" rowspan="1">T14.2 - T14.21</td></tr><tr><td colspan="1" rowspan="1">M80.- Osteoporose mit pathologischer Fraktur</td><td colspan="1" rowspan="1">M80.0 - M80.99</td></tr></table></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;">1.2.276.0.76.3.1.261.1.10.3.6</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2018‑06‑04</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Entwurf</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;">Dischargediagnosissection2</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Entlassungsdiagnose</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beschreibung</th><td style="text-align: left;" colspan="3">Diagnose, mit der der Patient entlassen wurde<br /></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Section 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;">Assoziiert mit</th><td style="text-align: left;" colspan="3"><table class="treetable" id="assocsTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Assoziiert mit 1 Konzept</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;">Id</th><th style="width: 60%; text-align: left;">Name</th><th style="width: 20%; text-align: left;">Datensatz</th></tr><tr><td style="text-align: left; vertical-align: top; width: 1%;"><span style="color: grey;">dguvbbr-data&#8203;element2-</span>100</td><td style="vertical-align: top;">[[File:Kyellow.png|14px]] Diagnosen/Probleme </td><td style="text-align: left; vertical-align: top;">[[File:Kyellow.png|14px]] Stationärer Entlassungsbericht  </td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">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 2 Templates</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</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;">1.2.276.0.76.3.1.261.1.10.4.14</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Diagnose Observation</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.276.0.76.3.1.261.1.10.4.7</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Klassifikation Observation</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 2.16.840.1.113883.10.12.201 <i> </i> (2005‑09‑07)</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 zur Textformatierung der Diagnosen in Form von Tabellen</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">section</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">1.2.276.0.76.3.1.261.1.10.3.2</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">29548-5</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.1</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">LOINC</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">title</span><span class="ppsign">&gt;</span><span class="pptext">Entlassungsdiagnosen</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">title</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">text</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">table</span> <span class="ppattribute">border</span><span class="ppsign">="</span><span class="ppcontent">1</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">thead</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">th</span><span class="ppsign">&gt;</span><span class="pptext">Diagnose</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">th</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">th</span><span class="ppsign">&gt;</span><span class="pptext">ICD Code</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">th</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">th</span><span class="ppsign">&gt;</span><span class="pptext">Lokalisation</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">th</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">th</span><span class="ppsign">&gt;</span><span class="pptext">Zusatz</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">th</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">thead</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">tbody</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">        <span class="ppsign">&lt;</span><span class="ppelement">tr</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">            <span class="ppsign">&lt;</span><span class="ppelement">content</span> <span class="ppattribute">ID</span><span class="ppsign">="</span><span class="ppcontent">diag_1</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><span class="pptext">Beckenringfraktur</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">content</span><span class="ppsign">&gt;</span></span>          <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span><span class="ppsign">&gt;</span><span class="pptext">S32.8</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span><span class="ppsign">&gt;</span><span class="pptext">--</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">          <span class="ppsign">&lt;</span><span class="ppelement">td</span><span class="ppsign">&gt;</span><span class="pptext">G</span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">td</span><span class="ppsign">&gt;</span></span>        <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">tr</span><span class="ppsign">&gt;</span></span>      <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">tbody</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">table</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">text</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">section</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:section<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="">(Dis...on2)</span></td></tr><tr style="vertical-align: top;"><td style="background-color: white;"> </td><td colspan="5" style="background-color: #F4FFF4;" class="tabtab"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr><td style="vertical-align: top; width: 20px" rowspan="2">[[File:Target.png|14px]]</td></tr><tr xmlns="" style="background-color: #F4FFF4;"><td style="width: 25%; vertical-align: top;"><span xmlns="http://www.w3.org/1999/xhtml" style="color: grey;">dguvbbr-data&#8203;element2-</span>100</td><td style="vertical-align: top;">[[File:Kyellow.png|14px]] Diagnosen/Probleme </td><td style="width: 35%; vertical-align: top;">[[File:Kyellow.png|14px]] Stationärer Entlassungsbericht  </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: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="">(Dis...on2)</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">1.2.276.0.76.3.1.261.1.10.3.6</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="">(Dis...on2)</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">11535-2</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">2.16.840.1.113883.6.1 (LOINC)</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:title<br /></strong></tt></td></tr></table></td><td><strong>ST</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="">(Dis...on2)</span></td></tr><tr style="vertical-align: top; background-color: #FFEEEE;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4" style="background-color: white;"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Elementinhalt muss "Entlassungsdiagnosen" sein</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:text<br /></strong></tt></td></tr></table></td><td><strong>SD.TEXT</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="">(Dis...on2)</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:entry<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.276.0.76.3.1.261.1.10.4.14 <i>Diagnose Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Dis...on2)</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 = '52534-5' and @codeSystem = '2.16.840.1.113883.6.1') or (@code = '81885-6' and @codeSystem = '2.16.840.1.113883.6.1')]]]</i></td></tr></table></td><td></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">.//hl7:observation[hl7:templateId/@root='1.2.276.0.76.3.1.261.1.10.4.14']/hl7:code[@code=('52534-5','81885-6')]</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">Der Code für die Diagnose-Observation muss 52534-5 LOIINC für die Hauptdiagnose oder 81885-6 LOINC für die Nebendiagnosen sein</span></td><td style="background-color: white;"> </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:entry<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.276.0.76.3.1.261.1.10.4.7 <i>Klassifikation Observation</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(Dis...on2)</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 [concat(@code, @codeSystem) = doc('include/voc-1.2.276.0.76.3.1.261.1.11.8-DYNAMIC.xml')//valueSet [1]/conceptList/concept/concat(@code, @codeSystem)]]]</i></td></tr></table></td><td></td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4">AO-Klassifikation ausfüllen, wenn die Hauptdiagnose laut ICD-10 eine Fraktur ist<br /><br /><table class="artdecor" style="background: transparent;"><tr><th colspan="1" rowspan="1">Region/Klasse</th><th colspan="1" rowspan="1">Code inkl. aller Unterklassen</th></tr><tr><td colspan="1" rowspan="1">S02.- Fraktur des Schädels und der Gesichtsschädelknochen</td><td colspan="1" rowspan="1">S02.0 - S02.09</td></tr><tr><td colspan="1" rowspan="1">S12.- Fraktur im Bereich des Halses</td><td colspan="1" rowspan="1">S12.0 - S12.9</td></tr><tr><td colspan="1" rowspan="1">S22.- Fraktur der Rippe(n), des Sternums und der Brustwirbelsäule</td><td colspan="1" rowspan="1">S22.0 - S22.9</td></tr><tr><td colspan="1" rowspan="1">S32.- Fraktur der Lendenwirbelsäule und des Beckens</td><td colspan="1" rowspan="1">S32.0 - S32.89</td></tr><tr><td colspan="1" rowspan="1">S42.- Fraktur im Bereich der Schulter und des Oberarmes</td><td colspan="1" rowspan="1">S42.0 - S42.9</td></tr><tr><td colspan="1" rowspan="1">S52.- Fraktur des Unterarmes</td><td colspan="1" rowspan="1">S52.0 - S52.9</td></tr><tr><td colspan="1" rowspan="1">S62.- Fraktur im Bereich des Handgelenkes und der Hand</td><td colspan="1" rowspan="1">S62.0 - S62.8</td></tr><tr><td colspan="1" rowspan="1">S72.- Fraktur des Femurs</td><td colspan="1" rowspan="1">S72.0 - S72.9</td></tr><tr><td colspan="1" rowspan="1">S82.- Fraktur des Unterschenkels, einschließlich des oberen Sprunggelenkes</td><td colspan="1" rowspan="1">S82.0 - S82.9</td></tr><tr><td colspan="1" rowspan="1">S92.- Fraktur des Fußes [ausgenommen oberes Sprunggelenk]</td><td colspan="1" rowspan="1">S92.0 - S92.9</td></tr><tr><td colspan="1" rowspan="1">T02.- Frakturen mit Beteiligung mehrerer Körperregionen</td><td colspan="1" rowspan="1">T02.0 - T02.91</td></tr><tr><td colspan="1" rowspan="1">T08.- Fraktur der Wirbelsäule, Höhe nicht näher bezeichnet</td><td colspan="1" rowspan="1">T08.0 - T08.1</td></tr><tr><td colspan="1" rowspan="1">T10.- Fraktur der oberen Extremität, Höhe nicht näher bezeichnet</td><td colspan="1" rowspan="1">T10.0 - T10.1</td></tr><tr><td colspan="1" rowspan="1">T12.- Fraktur der unteren Extremität, Höhe nicht näher bezeichnet</td><td colspan="1" rowspan="1">T12.0 - T12.1</td></tr><tr><td colspan="1" rowspan="1">T14.- Verletzung an einer nicht näher bezeichneten Körperregion</td><td colspan="1" rowspan="1">T14.2 - T14.21</td></tr><tr><td colspan="1" rowspan="1">M80.- Osteoporose mit pathologischer Fraktur</td><td colspan="1" rowspan="1">M80.0 - M80.99</td></tr></table></td></tr></table></td></tr></table>

Version vom 26. August 2018, 02:58 Uhr

Id1.2.276.0.76.3.1.261.1.10.3.6Gültigkeit2018‑06‑04
StatusKyellow.png EntwurfVersions-Label
NameDischargediagnosissection2AnzeigenameEntlassungsdiagnose
BeschreibungDiagnose, mit der der Patient entlassen wurde
KlassifikationCDA Section level template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Assoziiert mit
Assoziiert mit 1 Konzept
IdNameDatensatz
dguvbbr-data​element2-100Kyellow.png Diagnosen/Probleme Kyellow.png Stationärer Entlassungsbericht
Benutzt
Benutzt 2 Templates
Benutzt als NameVersion
1.2.276.0.76.3.1.261.1.10.4.14ContainmentKyellow.png Diagnose ObservationDYNAMIC
1.2.276.0.76.3.1.261.1.10.4.7ContainmentKyellow.png Klassifikation ObservationDYNAMIC
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Beispiel
Beispiel zur Textformatierung der Diagnosen in Form von Tabellen
<section>
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    <table border="1">
      <thead>
        <tr>
          <th>Diagnose</th>          <th>ICD Code</th>          <th>Lokalisation</th>          <th>Zusatz</th>        </tr>
      </thead>
      <tbody>
        <tr>
          <td>
            <content ID="diag_1">Beckenringfraktur</content>          </td>
          <td>S32.8</td>          <td>--</td>          <td>G</td>        </tr>
      </tbody>
    </table>
  </text>
</section>
ItemDTKardKonfBeschreibungLabel
hl7:section
(Dis...on2)
 
Target.png
dguvbbr-data​element2-100Kyellow.png Diagnosen/Probleme Kyellow.png Stationärer Entlassungsbericht
Treetree.pnghl7:templateId
II1 … 1(Dis...on2)
Treeblank.pngTreetree.png@root
uid1 … 1F1.2.276.0.76.3.1.261.1.10.3.6
Treetree.pnghl7:code
CE1 … 1M(Dis...on2)
Treeblank.pngTreetree.png@code
CONF1 … 1F11535-2
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1M(Dis...on2)
 CONF
Elementinhalt muss "Entlassungsdiagnosen" sein
Treetree.pnghl7:text
SD.TEXT1 … 1M(Dis...on2)
Treetree.pnghl7:entry
0 … *RBeinhaltet 1.2.276.0.76.3.1.261.1.10.4.14 Diagnose Observation (DYNAMIC)(Dis...on2)
Treeblank.png wo [hl7:observation [hl7:code [(@code = '52534-5' and @codeSystem = '2.16.840.1.113883.6.1') or (@code = '81885-6' and @codeSystem = '2.16.840.1.113883.6.1')]]]
 Schematron assertroleKred.png error 
 test.//hl7:observation[hl7:templateId/@root='1.2.276.0.76.3.1.261.1.10.4.14']/hl7:code[@code=('52534-5','81885-6')] 
 MeldungDer Code für die Diagnose-Observation muss 52534-5 LOIINC für die Hauptdiagnose oder 81885-6 LOINC für die Nebendiagnosen sein 
Treetree.pnghl7:entry
0 … *RBeinhaltet 1.2.276.0.76.3.1.261.1.10.4.7 Klassifikation Observation (DYNAMIC)(Dis...on2)
Treeblank.png wo [hl7:observation [hl7:code [concat(@code, @codeSystem) = doc('include/voc-1.2.276.0.76.3.1.261.1.11.8-DYNAMIC.xml')//valueSet [1]/conceptList/concept/concat(@code, @codeSystem)]]]
 ConstraintAO-Klassifikation ausfüllen, wenn die Hauptdiagnose laut ICD-10 eine Fraktur ist

Region/KlasseCode inkl. aller Unterklassen
S02.- Fraktur des Schädels und der GesichtsschädelknochenS02.0 - S02.09
S12.- Fraktur im Bereich des HalsesS12.0 - S12.9
S22.- Fraktur der Rippe(n), des Sternums und der BrustwirbelsäuleS22.0 - S22.9
S32.- Fraktur der Lendenwirbelsäule und des BeckensS32.0 - S32.89
S42.- Fraktur im Bereich der Schulter und des OberarmesS42.0 - S42.9
S52.- Fraktur des UnterarmesS52.0 - S52.9
S62.- Fraktur im Bereich des Handgelenkes und der HandS62.0 - S62.8
S72.- Fraktur des FemursS72.0 - S72.9
S82.- Fraktur des Unterschenkels, einschließlich des oberen SprunggelenkesS82.0 - S82.9
S92.- Fraktur des Fußes [ausgenommen oberes Sprunggelenk]S92.0 - S92.9
T02.- Frakturen mit Beteiligung mehrerer KörperregionenT02.0 - T02.91
T08.- Fraktur der Wirbelsäule, Höhe nicht näher bezeichnetT08.0 - T08.1
T10.- Fraktur der oberen Extremität, Höhe nicht näher bezeichnetT10.0 - T10.1
T12.- Fraktur der unteren Extremität, Höhe nicht näher bezeichnetT12.0 - T12.1
T14.- Verletzung an einer nicht näher bezeichneten KörperregionT14.2 - T14.21
M80.- Osteoporose mit pathologischer FrakturM80.0 - M80.99