cdaeau:Beispiel
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="xERST_END" codeSystem="2.16.840.1.113883.6.1" displayName="Arbeitsunfähigkeitserst-/-endbescheinigung"/>
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 <component>
92 <structuredBody>
93 <!-- Versicherung Section -->
94 <component typeCode="COMP" >
95 <section>
96 <templateId root="???????"/>
97 <code code="48768-0" codeSystem="2.16.840.1.113883.6.1"/>
98 <title>Versicherung</title>
99 <!-- Versicherung/Coverage -->
100 <entry>
101 <act classCode="ACT" moodCode="EVN">
102 <templateId/>
103 <id/>
104 <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" />
105 <statusCode code="completed"/>
106 <entryRelationship typeCode="COMP" sequenceNumber="1">
107 <!-- Versicherungspolicy -->
108 <act>
109 <templateId root="VERSICHERUNG" />
110 <code code="" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
111 <statusCode code="completed"/>
112 <!-- Payer Information -->
113 <performer>
114 <assignedEntity>
115 <id extension="Kassen-ID-47" />
116 <addr>
117 <streetAddressLine>AOK-Weg 1459</streetAddressLine>
118 <postalCode>10111</postalCode>
119 <city>Berlin</city>
120 </addr>
121 <representedOrganization>
122 <name>Versicherung AOK Berlin</name>
123 </representedOrganization>
124 </assignedEntity>
125 </performer>
126 <!-- Guarantor -->
127 <performer/>
128 <!-- Versicherung -->
129 <participant typeCode="COV">
130 <time>
131 <high value="20181231"/>
132 </time>
133 <participantRole>
134 <!-- Versichertenstatus -->
135 <code code="1">aaaaaaaaaaaa</code>
136 </participantRole>
137 </participant>
138 <!-- Versicherter -->
139 <participant typeCode="HLD">
140 <participantRole>
141 <id extension="VNR=4711">fgsdff</id>
142 </participantRole>
143 </participant>
144 </act>
145 </entryRelationship>
146 </act>
147 </entry>
148 </section>
149 </component>
150 <!-- AU-Diagnose Section -->
151 <component>
152 <section>
153 <templateId root=""/>
154 <code code="AU-DIAGNOSIS" />
155 <title>AU-begründende Diagnosen</title>
156 <text>Der Patient will einfach nicht arbeiten!</text>
157 <entry>
158 <observation classCode="OBS" moodeCode="EVN">
159 <code code="x47"/>
160 <statusCode code="completed"/>
161 </observation>
162 </entry>
163 <entry>
164 <observation classCode="OBS" moodeCode="EVN">
165 <code code="x80"/>
166 <statusCode code="completed"/>
167 </observation>
168 </entry>
169 </section>
170 </component>
171 <!-- Findings Section -->
172 <component>
173 <section>
174 <templateId/>
175 <text>
176
177 </text>
178 </section>
179 </component>
180 <!-- Accident/Unfall Section -->
181 <component>
182 <section>
183 <templateId/>
184 <code code="ACCIDENT"/>
185 <title>Unfall</title>
186 <entry>
187 <observation>
188 <templateId/>
189 <code code="ACCIDENT"/>
190 <statusCode code="completed"/>
191 <effectiveTime/>
192 <value code="D-ARZT" codeSystem="S_KBV_01_Accident"/>
193 </observation>
194 </entry>
195 </section>
196 </component>
197 <!-- Treatment Section -->
198 <component>
199 <section>
200 <templateId/>
201 <code code="TREATMENT"/>
202 <title>Einleitung besonderer Maßnahmen</title>
203 <text>
204 keine Ahnung, was sonst noch zu tun ist
205 </text>
206 <!-- Treatment stufenweise Wiedereingliederung -->
207 <entry>
208 <observation>
209 <code code="EINGLIEDERUNG" />
210 <value xsi:type="BL" value="false"/>
211 </observation>
212 </entry>
213 <!-- Treatment Leistungen med. Reha Observation -->
214 <entry>
215 <observation>
216 <code code="REHA" />
217 <value xsi:type="BL" value="true"/>
218 </observation>
219 </entry>
220 </section>
221 </component>
222 <!-- Temporary Disablement Section -->
223 <component>
224 <section>
225 <templateId/>
226 <code code="TEMPDISABLE"/>
227 <title>Arbeitsunfähigkeit</title>
228 <entry>
229 <observation>
230 <code code="X-IATWRK" codeSystem="2.16.840.1.113883.6.1"/>
231 <statusCode code="completed"/>
232 <text>
233
234 </text>
235 <effectiveTime>
236 <!-- Zeitraum der Arbeitsunfähigkeit -->
237 <low value="20171018"/>
238 <high value="20171020"/>
239 </effectiveTime>
240 <value xsi:type="INT" unit="%" value="100" />
241 <performer>
242 <!-- festgestellt am -->
243 <time value="20171019"/>
244 <assignedEntity>
245 <id/>
246 <assignedPerson>
247 <name>Hugo Müller</name>
248 </assignedPerson>
249 </assignedEntity>
250 </performer>
251 </observation>
252 </entry>
253 </section>
254 </component>
255 </structuredBody>
256 </component>
257</ClinicalDocument>
