2.16.840.1.113883.3.1937.99.61.34.10.28/hgraph

Aus Hl7wiki

Wechseln zu: Navigation, Suche

Document
PflegerischerEntlassungsbericht (2.16.840.1.113883.3.1937.99.61.34.10.28)
1. Header
  CDA realmCode (1.2.276.0.76.10.90002)
2. Header
  CDA typeId (1.2.276.0.76.10.90003)
3. Header
  CDA id (1.2.276.0.76.10.90004)
4. Header
  CDA effectiveTime (1.2.276.0.76.10.90006)
5. Header
  CDA confidentialityCode (1.2.276.0.76.10.90007)
6. Header
  CDA languageCode (1.2.276.0.76.10.90008)
7. Header
  CDA setId and versionNumber (1.2.276.0.76.10.90009)
8. Header
  CDA recordTarget (1.2.276.0.76.10.2001)
  1. *
    Personenname (1.2.276.0.76.10.90030)
9. Header
  CDA author (1.2.276.0.76.10.2002)
  1. Header
    CDA Person Elements (1.2.276.0.76.10.90010)
  2. Header
    CDA Organization Elements (1.2.276.0.76.10.90011)
10. Header
  CDA dataEnterer (1.2.276.0.76.10.2017)
  1. Header
    CDA Assigned Entity Elements (1.2.276.0.76.10.90012)
    1. Header
      CDA Person Elements (1.2.276.0.76.10.90010)
    2. Header
      CDA Organization Elements (1.2.276.0.76.10.90011)
11. *
  CDA Informant (1.2.276.0.76.10.2018)
  1. Header
    CDA Assigned Entity Elements (1.2.276.0.76.10.90012)
    1. Header
      CDA Person Elements (1.2.276.0.76.10.90010)
    2. Header
      CDA Organization Elements (1.2.276.0.76.10.90011)
  2. Entry
    RelatedEntity (Body) (1.2.276.0.76.10.90020)
    1. Header
      CDA Person Elements (1.2.276.0.76.10.90010)
12. Header
  CDA custodian (1.2.276.0.76.10.2004)
13. Header
  CDA informationRecipient (1.2.276.0.76.10.2005)
  1. Header
    CDA Person Elements (1.2.276.0.76.10.90010)
  2. Header
    CDA Organization Elements (1.2.276.0.76.10.90011)
14. Header
  CDA legalAuthenticator (1.2.276.0.76.10.2020)
  1. Header
    CDA Assigned Entity Elements (1.2.276.0.76.10.90012)
    1. Header
      CDA Person Elements (1.2.276.0.76.10.90010)
    2. Header
      CDA Organization Elements (1.2.276.0.76.10.90011)
15. Header
  CDA authenticator (1.2.276.0.76.10.2019)
  1. Header
    CDA Assigned Entity Elements (1.2.276.0.76.10.90012)
    1. Header
      CDA Person Elements (1.2.276.0.76.10.90010)
    2. Header
      CDA Organization Elements (1.2.276.0.76.10.90011)
16. Header
  CDA participant Angehörige (1.2.276.0.76.10.2021)
  1. Header
    CDA Person Elements (1.2.276.0.76.10.90010)
  2. Header
    CDA Organization Elements (1.2.276.0.76.10.90011)
17. Header
  CDA participant Ansprechpartner (1.2.276.0.76.10.2025)
  1. Header
    CDA Person Elements (1.2.276.0.76.10.90010)
  2. Header
    CDA Organization Elements (1.2.276.0.76.10.90011)
18. Header
  CDA participant Betreuungsorganisation (1.2.276.0.76.10.2026)
  1. Header
    CDA Organization Elements (1.2.276.0.76.10.90011)
19. Header
  CDA participant Weitere Beteiligte (1.2.276.0.76.10.2024)
  1. Header
    CDA Person Elements (1.2.276.0.76.10.90010)
  2. Header
    CDA Organization Elements (1.2.276.0.76.10.90011)
20. Header
  CDA participant Einweiser (1.2.276.0.76.10.2023)
  1. Header
    CDA Person Elements (1.2.276.0.76.10.90010)
  2. Header
    CDA Organization Elements (1.2.276.0.76.10.90011)
21. Header
  CDA participant Hausarzt (1.2.276.0.76.10.2012)
  1. Header
    CDA Person Elements (1.2.276.0.76.10.90010)
  2. Header
    CDA Organization Elements (1.2.276.0.76.10.90011)
22. Section
  Anrede (1.2.276.0.76.10.3001)
23. Section
  Pflegeprozess Section (1.2.276.0.76.10.3003)
  1. Section
    Pflegediagnose Section (1.2.276.0.76.10.3004)
    1. Entry
      Pflegediagnose - Entry (2.16.840.1.113883.3.1937.99.61.34.10.27)
      1. Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
    2. Section
      Hilfsmittel (2.16.840.1.113883.3.1937.99.61.34.10.20)
      1. Entry
        Hilfsmittel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.38)
        
        Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
        
        notype
        Manufactured Product (2.16.840.1.113883.3.1937.99.61.34.10.40)
        
        Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
        
        notype
        Manufactured Material (2.16.840.1.113883.3.1937.99.61.34.10.39)
        
        notype
        Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
    3. Section
      Ätiologie Section (1.2.276.0.76.10.3007)
    4. Section
      Symptome Section (1.2.276.0.76.10.3008)
    5. Section
      Ressource Section (1.2.276.0.76.10.3009)
    6. Section
      Pflegeintervention Section (1.2.276.0.76.10.3010)
      1. Entry
        Pflegeintervention - Entry (2.16.840.1.113883.3.1937.99.61.34.10.30)
        
        Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
      2. Section
        Pflegeergebnis Section (1.2.276.0.76.10.3011)
        
        Entry
        Pflegeergebnis - Entry (2.16.840.1.113883.3.1937.99.61.34.10.31)
        
        Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
  2. Section
    Assessment Section_Pflegebericht (2.16.840.1.113883.3.1937.99.61.34.10.42)
    1. Entry
      Score - Entry (2.16.840.1.113883.3.1937.99.61.34.10.29)
      1. Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
    2. Section
      Hilfsmittel (2.16.840.1.113883.3.1937.99.61.34.10.20)
      1. Entry
        Hilfsmittel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.38)
        
        Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
        
        notype
        Manufactured Product (2.16.840.1.113883.3.1937.99.61.34.10.40)
        
        Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
        
        notype
        Manufactured Material (2.16.840.1.113883.3.1937.99.61.34.10.39)
        
        notype
        Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
    3. Section
      Pflegeziel Section (1.2.276.0.76.10.3006)
      1. Entry
        Pflegeziel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.32)
        
        Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
      2. Section
        Hilfsmittel (2.16.840.1.113883.3.1937.99.61.34.10.20)
        
        Entry
        Hilfsmittel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.38)
        
        Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
        
        notype
        Manufactured Product (2.16.840.1.113883.3.1937.99.61.34.10.40)
        
        Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
        
        notype
        Manufactured Material (2.16.840.1.113883.3.1937.99.61.34.10.39)
        
        notype
        Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
      3. Section
        Ressource Section (1.2.276.0.76.10.3009)
      4. Section
        Pflegeintervention Section (1.2.276.0.76.10.3010)
        
        Entry
        Pflegeintervention - Entry (2.16.840.1.113883.3.1937.99.61.34.10.30)
        
        Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
        
        Section
        Pflegeergebnis Section (1.2.276.0.76.10.3011)
        
        Entry
        Pflegeergebnis - Entry (2.16.840.1.113883.3.1937.99.61.34.10.31)
        
        Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
    4. Section
      Pflegeintervention Section (1.2.276.0.76.10.3010)
      1. Entry
        Pflegeintervention - Entry (2.16.840.1.113883.3.1937.99.61.34.10.30)
        
        Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
      2. Section
        Pflegeergebnis Section (1.2.276.0.76.10.3011)
        
        Entry
        Pflegeergebnis - Entry (2.16.840.1.113883.3.1937.99.61.34.10.31)
        
        Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
  3. Section
    Pflegeziel Section (1.2.276.0.76.10.3006)
    1. Entry
      Pflegeziel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.32)
      1. Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
    2. Section
      Hilfsmittel (2.16.840.1.113883.3.1937.99.61.34.10.20)
      1. Entry
        Hilfsmittel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.38)
        
        Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
        
        notype
        Manufactured Product (2.16.840.1.113883.3.1937.99.61.34.10.40)
        
        Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
        
        notype
        Manufactured Material (2.16.840.1.113883.3.1937.99.61.34.10.39)
        
        notype
        Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
    3. Section
      Ressource Section (1.2.276.0.76.10.3009)
    4. Section
      Pflegeintervention Section (1.2.276.0.76.10.3010)
      1. Entry
        Pflegeintervention - Entry (2.16.840.1.113883.3.1937.99.61.34.10.30)
        
        Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
      2. Section
        Pflegeergebnis Section (1.2.276.0.76.10.3011)
        
        Entry
        Pflegeergebnis - Entry (2.16.840.1.113883.3.1937.99.61.34.10.31)
        
        Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
  4. Section
    Pflegeintervention Section (1.2.276.0.76.10.3010)
    1. Entry
      Pflegeintervention - Entry (2.16.840.1.113883.3.1937.99.61.34.10.30)
      1. Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
    2. Section
      Pflegeergebnis Section (1.2.276.0.76.10.3011)
      1. Entry
        Pflegeergebnis - Entry (2.16.840.1.113883.3.1937.99.61.34.10.31)
        
        Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
24. Section
  SocialInformation (2.16.840.1.113883.3.1937.99.61.34.10.8)
  1. Section
    Ausgeübter Beruf (2.16.840.1.113883.3.1937.99.61.34.10.2)
25. Section
  HomeCareStatus (2.16.840.1.113883.3.1937.99.61.34.10.21)
  1. Section
    Barrierefreiheit (2.16.840.1.113883.3.1937.99.61.34.10.17)
    1. Section
      Zugang zur Wohnung (2.16.840.1.113883.3.1937.99.61.34.10.16)
    2. Section
      Barrierefreiheit in der Wohnung (2.16.840.1.113883.3.1937.99.61.34.10.15)
    3. Section
      Wohnraumanpassung (2.16.840.1.113883.3.1937.99.61.34.10.14)
      1. notype
        Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
    4. Section
      Wohnumfeldberatung (2.16.840.1.113883.3.1937.99.61.34.10.13)
  2. Section
    Wohnform (2.16.840.1.113883.3.1937.99.61.34.10.19)
    1. Entry
      Wohnform - Entry (2.16.840.1.113883.3.1937.99.61.34.10.41)
      1. Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
  3. Section
    Hilfsmittel (2.16.840.1.113883.3.1937.99.61.34.10.20)
    1. Entry
      Hilfsmittel - Entry (2.16.840.1.113883.3.1937.99.61.34.10.38)
      1. Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
      2. notype
        Manufactured Product (2.16.840.1.113883.3.1937.99.61.34.10.40)
        
        Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
        
        notype
        Manufactured Material (2.16.840.1.113883.3.1937.99.61.34.10.39)
      3. notype
        Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
26. Section
  Sozialrechtliche Informationen (2.16.840.1.113883.3.1937.99.61.34.10.26)
  1. Section
    Bestellung eines Betreuers (2.16.840.1.113883.3.1937.99.61.34.10.25)
    1. Entry
      Betreuer (2.16.840.1.113883.3.1937.99.61.34.10.34)
      1. Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
    2. Entry
      Vormundschaftsgericht (2.16.840.1.113883.3.1937.99.61.34.10.33)
      1. Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
  2. Section
    Hilfe nach SGB XII (2.16.840.1.113883.3.1937.99.61.34.10.24)
    1. Entry
      Hilfe zur Pflege nach SGB XII (L3) (2.16.840.1.113883.3.1937.99.61.34.10.35)
    2. notype
      Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
    3. *
      spezielle Kontaktperson (2.16.840.1.113883.3.1937.99.61.34.10.43)
  3. Section
    Pflegegrad (2.16.840.1.113883.3.1937.99.61.34.10.9)
    1. Entry
      Pflegegrad (2.16.840.1.113883.3.1937.99.61.34.10.7)
      1. notype
        Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
    2. notype
      Kontaktorganisation (2.16.840.1.113883.3.1937.99.61.34.10.37)
    3. *
      spezielle Kontaktperson (2.16.840.1.113883.3.1937.99.61.34.10.43)
  4. Section
    Verfügungen (2.16.840.1.113883.3.1937.99.61.34.10.22)
    1. Entry
      Verfügungen - Entry (2.16.840.1.113883.3.1937.99.61.34.10.36)
      1. Header
        CDA effectiveTime (1.2.276.0.76.10.90006)
    2. Header
      CDA custodian (1.2.276.0.76.10.2004)
27. Section
  Medizinische Informationen (2.16.840.1.113883.3.1937.99.61.34.10.4)
  1. Section
    Aufnahmediagnose (1.2.276.0.76.10.3026)
    1. Entry
      Diagnose Concern Act (1.2.276.0.76.10.4079)
      1. Entry
        Author (Body) (1.2.276.0.76.10.90025)
        
        Header
        CDA Person Elements (1.2.276.0.76.10.90010)
        
        Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
      2. Entry
        Diagnose Observation (1.2.276.0.76.10.4080)
        
        Entry
        Lateralität (1.2.276.0.76.10.90026)
        
        Entry
        Diagnosesicherheit (1.2.276.0.76.10.90027)
        
        Entry
        Author (Body) (1.2.276.0.76.10.90025)
        
        Header
        CDA Person Elements (1.2.276.0.76.10.90010)
        
        Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
        
        Entry
        Alter Beobachtung (1.2.276.0.76.10.4077)
        
        Entry
        Prognose Observation (1.2.276.0.76.10.4078)
        
        Entry
        Priorität Präferenz (1.2.276.0.76.10.4076)
        
        Entry
        Author (Body) (1.2.276.0.76.10.90025)
        
        Header
        CDA Person Elements (1.2.276.0.76.10.90010)
        
        Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
        
        Entry
        Manifestation Observation (1.2.276.0.76.10.4093)
        
        Entry
        Etiology Observation (1.2.276.0.76.10.4094)
      3. Entry
        Priorität Präferenz (1.2.276.0.76.10.4076)
        
        Entry
        Author (Body) (1.2.276.0.76.10.90025)
        
        Header
        CDA Person Elements (1.2.276.0.76.10.90010)
        
        Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
  2. Section
    Entlassungsdiagnose (1.2.276.0.76.10.3027)
    1. Entry
      Diagnose Concern Act (1.2.276.0.76.10.4079)
      1. Entry
        Author (Body) (1.2.276.0.76.10.90025)
        
        Header
        CDA Person Elements (1.2.276.0.76.10.90010)
        
        Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
      2. Entry
        Diagnose Observation (1.2.276.0.76.10.4080)
        
        Entry
        Lateralität (1.2.276.0.76.10.90026)
        
        Entry
        Diagnosesicherheit (1.2.276.0.76.10.90027)
        
        Entry
        Author (Body) (1.2.276.0.76.10.90025)
        
        Header
        CDA Person Elements (1.2.276.0.76.10.90010)
        
        Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
        
        Entry
        Alter Beobachtung (1.2.276.0.76.10.4077)
        
        Entry
        Prognose Observation (1.2.276.0.76.10.4078)
        
        Entry
        Priorität Präferenz (1.2.276.0.76.10.4076)
        
        Entry
        Author (Body) (1.2.276.0.76.10.90025)
        
        Header
        CDA Person Elements (1.2.276.0.76.10.90010)
        
        Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
        
        Entry
        Manifestation Observation (1.2.276.0.76.10.4093)
        
        Entry
        Etiology Observation (1.2.276.0.76.10.4094)
      3. Entry
        Priorität Präferenz (1.2.276.0.76.10.4076)
        
        Entry
        Author (Body) (1.2.276.0.76.10.90025)
        
        Header
        CDA Person Elements (1.2.276.0.76.10.90010)
        
        Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
  3. Section
    Medikation bei Einweisung (Historie) (1.2.276.0.76.10.3029)
    1. Entry
      Medikation (1.2.276.0.76.10.4022)
      1. Entry
        Author (Body) (1.2.276.0.76.10.90025)
        
        Header
        CDA Person Elements (1.2.276.0.76.10.90010)
        
        Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
      2. Entry
        RelatedEntity (Body) (1.2.276.0.76.10.90020)
        
        Header
        CDA Person Elements (1.2.276.0.76.10.90010)
      3. Entry
        Einzeldosierungen (1.2.276.0.76.10.4023)
      4. Entry
        Dosierung Freitext (1.2.276.0.76.10.4024)
  4. Section
    Medikation bei Entlassung (1.2.276.0.76.10.3031)
    1. Entry
      Medikation (1.2.276.0.76.10.4022)
      1. Entry
        Author (Body) (1.2.276.0.76.10.90025)
        
        Header
        CDA Person Elements (1.2.276.0.76.10.90010)
        
        Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
      2. Entry
        RelatedEntity (Body) (1.2.276.0.76.10.90020)
        
        Header
        CDA Person Elements (1.2.276.0.76.10.90010)
      3. Entry
        Einzeldosierungen (1.2.276.0.76.10.4023)
      4. Entry
        Dosierung Freitext (1.2.276.0.76.10.4024)
  5. Section
    Verabreichte Medikation während des Aufenthalts (1.2.276.0.76.10.3030)
    1. Entry
      Medikation (1.2.276.0.76.10.4022)
      1. Entry
        Author (Body) (1.2.276.0.76.10.90025)
        
        Header
        CDA Person Elements (1.2.276.0.76.10.90010)
        
        Header
        CDA Organization Elements (1.2.276.0.76.10.90011)
      2. Entry
        RelatedEntity (Body) (1.2.276.0.76.10.90020)
        
        Header
        CDA Person Elements (1.2.276.0.76.10.90010)
      3. Entry
        Einzeldosierungen (1.2.276.0.76.10.4023)
      4. Entry
        Dosierung Freitext (1.2.276.0.76.10.4024)
28. Section
  Abschließende Bemerkungen (1.2.276.0.76.10.3034)
29. Section
  Beilagen/Anhang (1.2.276.0.76.10.3037)
  1. Entry
    Eingebettetes Objekt Entry (1.2.276.0.76.10.4014)

Abgerufen von „https://wiki.hl7.de/index.php?title=2.16.840.1.113883.3.1937.99.61.34.10.28/hgraph&oldid=73539“