cdaeau:Beispiel: Unterschied zwischen den Versionen

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Zeile 4: Zeile 4:
 
<?xml version="1.0" encoding="UTF-8"?>
 
<?xml version="1.0" encoding="UTF-8"?>
 
<?xml-stylesheet type="text/xsl" href="eau.xslt"?>
 
<?xml-stylesheet type="text/xsl" href="eau.xslt"?>
 +
<?xml-model href="../../abde-runtime-develop/abde-abplus.sch" type="application/xml" schematypens="http://purl.oclc.org/dsdl/schematron"?>
 
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:pharm="urn:ihe:pharm:medication" xsi:schemaLocation="urn:hl7-org:v3 ../schemas/CDA.xsd">
 
<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:pharm="urn:ihe:pharm:medication" xsi:schemaLocation="urn:hl7-org:v3 ../schemas/CDA.xsd">
 
     <realmCode code="DE"/>
 
     <realmCode code="DE"/>
Zeile 9: Zeile 10:
 
     <templateId root="1.2.276.0.76.10.1020"/>
 
     <templateId root="1.2.276.0.76.10.1020"/>
 
     <id root="1.2.276.0.76.3645.239" extension="di-b02e97c1-3cea-4ed4-80cd-5d8a7386cee2" />
 
     <id root="1.2.276.0.76.3645.239" extension="di-b02e97c1-3cea-4ed4-80cd-5d8a7386cee2" />
     <code code="xERST_END" codeSystem="2.16.840.1.113883.6.1" displayName="Arbeitsunfähigkeitserst-/-endbescheinigung"/>
+
     <code code="85216-0" codeSystem="2.16.840.1.113883.6.1" displayName="Disability examination note"/>
 
     <title>eAU vom 25. Oktober 2017</title>
 
     <title>eAU vom 25. Oktober 2017</title>
 
     <effectiveTime value="20171025123415"/>
 
     <effectiveTime value="20171025123415"/>
Zeile 91: Zeile 92:
 
         </assignedEntity>
 
         </assignedEntity>
 
     </legalAuthenticator>
 
     </legalAuthenticator>
     <component>
+
     <documentationOf typeCode="DOC">
 +
<ServiceEvent classCode="ACT" moodCode="EVN">
 +
<code code="xFOLGE_END" codeSystem="1.2.276.0.76.11.456" displayName="Folgebescheinigung AU"/>
 +
</ServiceEvent>
 +
</documentationOf>
 +
<component>
 
         <structuredBody>
 
         <structuredBody>
 
             <!-- Versicherung Section -->
 
             <!-- Versicherung Section -->
Zeile 260: Zeile 266:
 
                     <entry>
 
                     <entry>
 
                         <observation classCode="OBS" moodCode="EVN">
 
                         <observation classCode="OBS" moodCode="EVN">
                             <code code="X-IATWRK" codeSystem="2.16.840.1.113883.6.1"/>
+
                             <code code="X-IATWRK" codeSystem="2.16.840.1.113883.6.1">
 +
<qualifier>
 +
<!-- auf für nach der 7. Woche -->
 +
<name code="x7AU"/>
 +
<value code="x7AU"/>
 +
</qualifier>
 +
</code>
 
                             <text>
 
                             <text>
 
                                 beliebiger Text
 
                                 beliebiger Text

Version vom 18. Dezember 2017, 16:38 Uhr

Nachfolgend ein Beispieldokument:

  1<?xml version="1.0" encoding="UTF-8"?>
  2<?xml-stylesheet type="text/xsl" href="eau.xslt"?>
  3<?xml-model href="../../abde-runtime-develop/abde-abplus.sch" type="application/xml" schematypens="http://purl.oclc.org/dsdl/schematron"?>
  4<ClinicalDocument xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:pharm="urn:ihe:pharm:medication" xsi:schemaLocation="urn:hl7-org:v3 ../schemas/CDA.xsd">
  5    <realmCode code="DE"/>
  6    <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
  7    <templateId root="1.2.276.0.76.10.1020"/>
  8    <id root="1.2.276.0.76.3645.239" extension="di-b02e97c1-3cea-4ed4-80cd-5d8a7386cee2" />
  9    <code code="85216-0" codeSystem="2.16.840.1.113883.6.1" displayName="Disability examination note"/>
 10    <title>eAU vom 25. Oktober 2017</title>
 11    <effectiveTime value="20171025123415"/>
 12    <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
 13    <languageCode code="de-DE"/>
 14    <setId root="1.2.276.0.76.3645.239" extension="si-b8a7b265-4e20-4177-8cfb-149491b8003a"/>
 15    <versionNumber value="1"/>
 16    <recordTarget>
 17        <patientRole>
 18            <id extension="1543627549" root="1.2.276.0.76.4.1"/>
 19            <addr>
 20                <streetAddressLine>Riedemannweg 59</streetAddressLine>
 21                <postalCode>13627</postalCode>
 22                <city>Berlin</city>
 23            </addr>
 24            <telecom use="HP" value="tel:030.456.345345"/>
 25            <patient>
 26                <name>
 27                    <given>Paul</given>
 28                    <family>Pappel</family>
 29                </name>
 30                <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
 31                <birthTime value="19551217"/>
 32                <birthplace>
 33                    <place>
 34                        <addr>
 35                            <city>Sassnitz</city>
 36                        </addr>
 37                    </place>
 38                </birthplace>
 39            </patient>
 40        </patientRole>
 41    </recordTarget>
 42    <author>
 43        <!--- author -->
 44        <time value="20151104"/>
 45        <assignedAuthor>
 46            <id extension="ied8984938" root="2.16.840.1.113883.3.67.933"/>
 47            <assignedPerson>
 48                <name>
 49                    <prefix qualifier="AC">Dr. med.</prefix>
 50                    <given>Theo</given>
 51                    <family>Phyllin</family>
 52                </name>
 53            </assignedPerson>
 54            <representedOrganization>
 55                <id extension="1443984938" root="BSNR"/>
 56                <name>Praxis Dr. med. Phyllin</name>
 57                <telecom use="WP" value="tel:0214.2127070"/>
 58                <telecom use="WP" value="tel:0214.212707122"/>
 59                <addr>
 60                    <streetName>Krankenhausstraße</streetName>
 61                    <houseNumber>240</houseNumber>
 62                    <postalCode>51371</postalCode>
 63                    <city>Leverkusen</city>
 64                </addr>
 65            </representedOrganization>
 66        </assignedAuthor>
 67    </author>
 68    <custodian>
 69        <assignedCustodian>
 70            <representedCustodianOrganization classCode="ORG" determinerCode="INSTANCE">
 71                <id extension="M345" root="1.2.276.0.58"/>
 72                <name>Praxis Dr. med. Phyllin</name>
 73                <telecom use="WP" value="tel:0214.2127070"/>
 74                <addr>
 75                    <streetName>Krankenhausstraße</streetName>
 76                    <houseNumber>240</houseNumber>
 77                    <postalCode>51371</postalCode>
 78                    <city>Leverkusen</city>
 79                </addr>
 80            </representedCustodianOrganization>
 81        </assignedCustodian>
 82    </custodian>
 83    <legalAuthenticator typeCode="LA" contextControlCode="OP">
 84        <time value="20171004"/>
 85        <signatureCode code="S"/>
 86        <assignedEntity>
 87            <!-- nur als ID (identisch zu author) -->
 88            <id extension="ied8984938" root="2.16.840.1.113883.3.67.933"/>
 89        </assignedEntity>
 90    </legalAuthenticator>
 91    <documentationOf typeCode="DOC">
 92		<ServiceEvent classCode="ACT" moodCode="EVN">
 93			<code code="xFOLGE_END" codeSystem="1.2.276.0.76.11.456" displayName="Folgebescheinigung AU"/>
 94		</ServiceEvent>
 95	</documentationOf>
 96	<component>
 97        <structuredBody>
 98            <!-- Versicherung Section -->
 99            <component typeCode="COMP" >
100                <section>
101                    <templateId root="xxxxxx"/>
102                    <code code="48768-0" codeSystem="2.16.840.1.113883.6.1"/>
103                    <title>Versicherung</title>
104                    <!-- Versicherung/Coverage -->
105                    <entry>
106                        <act classCode="ACT" moodCode="EVN">
107                            <templateId/>
108                            <id/>
109                            <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" />
110                            <statusCode code="completed"/>
111                            <entryRelationship typeCode="COMP">
112                                <!-- Versicherungspolicy -->
113                                <act classCode="ACT" moodCode="EVN">
114                                    <templateId root="VERSICHERUNG" />
115                                    <code code="VERSICHERUNG" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
116                                    <statusCode code="completed"/>
117                                    <!-- Payer Information -->
118                                    <performer>
119                                        <assignedEntity>
120                                            <id extension="Kassen-ID-47" />
121                                            <addr>
122                                                <streetAddressLine>AOK-Weg 1459</streetAddressLine>
123                                                <postalCode>10111</postalCode>
124                                                <city>Berlin</city>
125                                            </addr>
126                                            <representedOrganization>
127                                                <name>Versicherung AOK Berlin</name>
128                                            </representedOrganization>
129                                        </assignedEntity>
130                                    </performer>
131                                    <!-- Guarantor -->
132                                    <!--
133                                    <performer modeCode="WRITTEN" />
134                                    -->
135                                    <!-- Versicherung -->
136                                    <participant typeCode="COV">
137                                        <time>
138                                            <high value="20181231"/>
139                                        </time>
140                                        <participantRole>
141                                            <!-- Versichertenstatus -->
142                                            <code code="1"/>
143                                        </participantRole>
144                                    </participant>
145                                    <!-- Versicherter -->
146                                    <participant typeCode="HLD">
147                                        <participantRole>
148                                            <id root="xxxxxxxxx" extension="VNR=4711" />
149                                        </participantRole>
150                                    </participant>
151                                    <entryRelationship typeCode="COMP" >
152                                        <!-- Person Group Observation -->
153                                        <observation classCode="OBS" moodCode="EVN" >
154                                            <templateId root="PRSNGRP" />
155                                            <code code="PRSNGRP" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
156                                            <!-- aus S_KBV_PERSONENGRUPPE -->
157                                            <value xsi:type="CD" code="4" codeSystem="1.2.276.0.76.11.151" displayName="SOZ"/>
158                                        </observation>
159                                    </entryRelationship>
160                                    <entryRelationship typeCode="COMP" >
161                                        <!-- DMP Observation -->
162                                        <observation classCode="OBS" moodCode="EVN">
163                                            <templateId root="DMP" />
164                                            <code code="DMP" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
165                                            <!-- aus S_KBV_DMP -->
166                                            <value xsi:type="CD" code="D" codeSystem="1.2.276.0.76.11.138"/>
167                                        </observation>
168                                    </entryRelationship>
169                                    <entryRelationship typeCode="COMP" >
170                                        <!-- DMP Observation -->
171                                        <observation classCode="OBS" moodCode="EVN">
172                                            <templateId root="ASV" />
173                                            <code code="ASV" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
174                                            <!-- aus S_KBV_ASV -->
175                                            <value xsi:type="CD" code="A" />
176                                        </observation>
177                                    </entryRelationship>
178                                </act>
179                            </entryRelationship>
180                        </act>
181                    </entry>
182                </section>
183            </component>
184            <!-- AU-Diagnose Section -->
185            <component>
186                <section>
187                    <templateId root="xxxxxx"/>
188                    <code code="AU-DIAGNOSIS" />
189                    <title>AU-begründende Diagnosen</title>
190                    <text>Der Patient will einfach nicht arbeiten!</text>
191                    <entry>
192                        <observation classCode="OBS" moodCode="EVN">
193                            <code code="x47"/>
194                            <statusCode code="completed"/>
195                        </observation>
196                    </entry>
197                    <entry>
198                        <observation classCode="OBS" moodCode="EVN">
199                            <code code="x80"/>
200                            <statusCode code="completed"/>
201                        </observation>
202                    </entry>
203                </section>
204            </component>
205            <!-- Findings Section -->
206            <component>
207                <section>
208                    <templateId/>
209                    <text>
210                        
211                    </text>
212                </section>
213            </component>
214            <!-- Accident/Unfall Section -->
215            <component>
216                <section>
217                    <templateId/>
218                    <code code="ACCIDENT"/>
219                    <title>Unfall</title>
220                    <entry>
221                        <observation classCode="OBS" moodCode="EVN">
222                            <templateId/>
223                            <code code="ACCIDENT"/>
224                            <statusCode code="completed"/>
225                            <effectiveTime/>
226                            <!-- aus S_KBV_01_Accident -->
227                            <value xsi:type="CD" code="D-ARZT" codeSystem="1.2.276.0.76.3.1.135.8.11.4"/>
228                        </observation>
229                    </entry>
230                </section>
231            </component>
232            <!-- Treatment Section -->
233            <component>
234                <section>
235                    <templateId/>
236                    <code code="TREATMENT"/>
237                    <title>Einleitung besonderer Maßnahmen</title>
238                    <text>
239                        keine Ahnung, was sonst noch zu tun ist
240                    </text>
241                    <!-- Treatment stufenweise Wiedereingliederung -->
242                    <entry>
243                        <observation classCode="OBS" moodCode="EVN">
244                            <code code="EINGLIEDERUNG" />
245                            <value xsi:type="BL" value="false"/>
246                        </observation>
247                    </entry>
248                    <!-- Treatment Leistungen med. Reha Observation -->
249                    <entry>
250                        <observation classCode="OBS" moodCode="EVN">
251                            <code code="REHA" />
252                            <value xsi:type="BL" value="true"/>
253                        </observation>
254                    </entry>
255                </section>
256            </component>
257            <!-- Temporary Disablement Section -->
258            <component>
259                <section>
260                    <templateId/>
261                    <code code="TEMPDISABLE"/>
262                    <title>Arbeitsunfähigkeit</title>
263                    <entry>
264                        <observation classCode="OBS" moodCode="EVN">
265                            <code code="X-IATWRK" codeSystem="2.16.840.1.113883.6.1">
266								<qualifier>
267									<!-- auf für nach der 7. Woche -->
268									<name code="x7AU"/>
269									<value code="x7AU"/>
270								</qualifier>
271							</code>
272                            <text>
273                                beliebiger Text
274                            </text>
275                            <statusCode code="completed"/>
276                            <effectiveTime>
277                                <!-- Zeitraum der Arbeitsunfähigkeit -->
278                                <low value="20171018"/>
279                                <high value="20171020"/>
280                            </effectiveTime>
281                            <value xsi:type="PQ" unit="%" value="100" />
282                            <performer>
283                                <!-- festgestellt am -->
284                                <time value="20171019"/>
285                                <assignedEntity>
286                                    <id/>
287                                    <assignedPerson>
288                                        <name>Hugo Müller</name>
289                                    </assignedPerson>
290                                </assignedEntity>
291                            </performer>
292                        </observation>
293                    </entry>
294                </section>
295            </component>
296        </structuredBody>
297    </component>
298</ClinicalDocument>