cdaeau:Beispiel

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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="xxxxxx"/>
 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">
107                                <!-- Versicherungspolicy -->
108                                <act classCode="ACT" moodCode="EVN">
109                                    <templateId root="VERSICHERUNG" />
110                                    <code code="VERSICHERUNG" 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                                    <!--
128                                    <performer modeCode="WRITTEN" />
129                                    -->
130                                    <!-- Versicherung -->
131                                    <participant typeCode="COV">
132                                        <time>
133                                            <high value="20181231"/>
134                                        </time>
135                                        <participantRole>
136                                            <!-- Versichertenstatus -->
137                                            <code code="1"/>
138                                        </participantRole>
139                                    </participant>
140                                    <!-- Versicherter -->
141                                    <participant typeCode="HLD">
142                                        <participantRole>
143                                            <id root="xxxxxxxxx" extension="VNR=4711" />
144                                        </participantRole>
145                                    </participant>
146                                    <entryRelationship typeCode="COMP" >
147                                        <!-- Person Group Observation -->
148                                        <observation classCode="OBS" moodCode="EVN" >
149                                            <templateId root="PRSNGRP" />
150                                            <code code="PRSNGRP" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
151                                            <!-- aus S_KBV_PERSONENGRUPPE -->
152                                            <value xsi:type="CD" code="4" codeSystem="1.2.276.0.76.11.151" displayName="SOZ"/>
153                                        </observation>
154                                    </entryRelationship>
155                                    <entryRelationship typeCode="COMP" >
156                                        <!-- DMP Observation -->
157                                        <observation classCode="OBS" moodCode="EVN">
158                                            <templateId root="DMP" />
159                                            <code code="DMP" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
160                                            <!-- aus S_KBV_DMP -->
161                                            <value xsi:type="CD" code="D" codeSystem="1.2.276.0.76.11.138"/>
162                                        </observation>
163                                    </entryRelationship>
164                                    <entryRelationship typeCode="COMP" >
165                                        <!-- DMP Observation -->
166                                        <observation classCode="OBS" moodCode="EVN">
167                                            <templateId root="ASV" />
168                                            <code code="ASV" codeSystem="2.16.840.1.113883.3.88.12.3221.5.2" />
169                                            <!-- aus S_KBV_ASV -->
170                                            <value xsi:type="CD" code="A" />
171                                        </observation>
172                                    </entryRelationship>
173                                </act>
174                            </entryRelationship>
175                        </act>
176                    </entry>
177                </section>
178            </component>
179            <!-- AU-Diagnose Section -->
180            <component>
181                <section>
182                    <templateId root="xxxxxx"/>
183                    <code code="AU-DIAGNOSIS" />
184                    <title>AU-begründende Diagnosen</title>
185                    <text>Der Patient will einfach nicht arbeiten!</text>
186                    <entry>
187                        <observation classCode="OBS" moodCode="EVN">
188                            <code code="x47"/>
189                            <statusCode code="completed"/>
190                        </observation>
191                    </entry>
192                    <entry>
193                        <observation classCode="OBS" moodCode="EVN">
194                            <code code="x80"/>
195                            <statusCode code="completed"/>
196                        </observation>
197                    </entry>
198                </section>
199            </component>
200            <!-- Findings Section -->
201            <component>
202                <section>
203                    <templateId/>
204                    <text>
205                        
206                    </text>
207                </section>
208            </component>
209            <!-- Accident/Unfall Section -->
210            <component>
211                <section>
212                    <templateId/>
213                    <code code="ACCIDENT"/>
214                    <title>Unfall</title>
215                    <entry>
216                        <observation classCode="OBS" moodCode="EVN">
217                            <templateId/>
218                            <code code="ACCIDENT"/>
219                            <statusCode code="completed"/>
220                            <effectiveTime/>
221                            <!-- aus S_KBV_01_Accident -->
222                            <value xsi:type="CD" code="D-ARZT" codeSystem="1.2.276.0.76.3.1.135.8.11.4"/>
223                        </observation>
224                    </entry>
225                </section>
226            </component>
227            <!-- Treatment Section -->
228            <component>
229                <section>
230                    <templateId/>
231                    <code code="TREATMENT"/>
232                    <title>Einleitung besonderer Maßnahmen</title>
233                    <text>
234                        keine Ahnung, was sonst noch zu tun ist
235                    </text>
236                    <!-- Treatment stufenweise Wiedereingliederung -->
237                    <entry>
238                        <observation classCode="OBS" moodCode="EVN">
239                            <code code="EINGLIEDERUNG" />
240                            <value xsi:type="BL" value="false"/>
241                        </observation>
242                    </entry>
243                    <!-- Treatment Leistungen med. Reha Observation -->
244                    <entry>
245                        <observation classCode="OBS" moodCode="EVN">
246                            <code code="REHA" />
247                            <value xsi:type="BL" value="true"/>
248                        </observation>
249                    </entry>
250                </section>
251            </component>
252            <!-- Temporary Disablement Section -->
253            <component>
254                <section>
255                    <templateId/>
256                    <code code="TEMPDISABLE"/>
257                    <title>Arbeitsunfähigkeit</title>
258                    <entry>
259                        <observation classCode="OBS" moodCode="EVN">
260                            <code code="X-IATWRK" codeSystem="2.16.840.1.113883.6.1"/>
261                            <text>
262                                beliebiger Text
263                            </text>
264                            <statusCode code="completed"/>
265                            <effectiveTime>
266                                <!-- Zeitraum der Arbeitsunfähigkeit -->
267                                <low value="20171018"/>
268                                <high value="20171020"/>
269                            </effectiveTime>
270                            <value xsi:type="PQ" unit="%" value="100" />
271                            <performer>
272                                <!-- festgestellt am -->
273                                <time value="20171019"/>
274                                <assignedEntity>
275                                    <id/>
276                                    <assignedPerson>
277                                        <name>Hugo Müller</name>
278                                    </assignedPerson>
279                                </assignedEntity>
280                            </performer>
281                        </observation>
282                    </entry>
283                </section>
284            </component>
285        </structuredBody>
286    </component>
287</ClinicalDocument>