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[[Datei:Aufnahme_cda.png]]  
 
[[Datei:Aufnahme_cda.png]]  
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{| class="hl7table"
 +
! Lvl
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! RIM
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! Name
 +
! DT
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! Kard
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! Conf
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! Beschreibung
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 +
|-
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|1
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|bgcolor="ff8888"|act
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|Aufnahme
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|
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|null
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|null
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|
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|-
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|1
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|bgcolor="ff8888"|act
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|@classCode
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|CS CNE
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|1..1
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|M
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|DOCSECT
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|-
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|1
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|bgcolor="ff8888"|act
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|@moodCode
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|CS CNE
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|1..1
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|M
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|EVN
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|-
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|1
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|bgcolor="ff8888"|act
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|code
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|CD CWE
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|0..1
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|O
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|
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|-
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|1
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|bgcolor="ffaaaa"|rel
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|entry
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|
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|0..*
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|O
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|
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|-
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|2
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|bgcolor="ffaaaa"|rel
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|@typeCode
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|CS CNE
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|1..1
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|M
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|
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|-
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|2
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|bgcolor="ff8888"|act
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|Aufnahme
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|
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|0..*
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|O
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|
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|-
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|3
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|bgcolor="ff8888"|act
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|@classCode
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|CS CNE
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|1..1
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|M
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|OBS
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|-
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|3
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|bgcolor="ff8888"|act
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|@moodCode
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|CS CNE
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|1..1
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|M
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|EVN
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|-
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|3
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|bgcolor="ff8888"|act
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|code
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|CD CWE
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|1..1
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|O
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|
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|-
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|3
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|bgcolor="ff8888"|act
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|effectiveTime
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|TS
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|1..1
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|R
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|
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|-
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|3
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|bgcolor="ff8888"|act
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|effectiveTime
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|TS
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|1..1
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|R
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|
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|-
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|3
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|bgcolor="ccffff"|part
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|participant
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|
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|O
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|
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|-
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|-
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|4
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|@typeCode
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|1..1
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|M
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|
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|-
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|4
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|bgcolor="ff8888"|act
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|Mobilität
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|1..1
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|O
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|
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|-
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|5
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|@classCode
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|M
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|OBS
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|-
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|5
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|@moodCode
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|CS CNE
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|1..1
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|M
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|EVN
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|-
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|5
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|bgcolor="ff8888"|act
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|code
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|CD CWE
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|0..1
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|O
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|
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|-
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|5
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|bgcolor="ff8888"|act
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|value
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|ANY CWE
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|0..1
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|O
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|
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|-
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|3
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|bgcolor="ffaaaa"|rel
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|entry
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|
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|O
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|
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|-
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|4
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|bgcolor="ffaaaa"|rel
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|@typeCode
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|CS CNE
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|1..1
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|M
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|
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|-
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|4
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|bgcolor="ff8888"|act
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|Prognose
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|
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|0..*
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|O
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|
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|-
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|5
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|-
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|5
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|@moodCode
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|CS CNE
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|M
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|EVN
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|-
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|5
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|O
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|-
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|5
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|1..1
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|M
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|
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|-
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|4
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|bgcolor="ff8888"|act
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|BesondererAufwandMit
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|
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|0..*
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|O
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|
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|5
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|5
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|bgcolor="ff8888"|act
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|M
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|-
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|code
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|0..1
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|O
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|
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|-
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|
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|4
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|bgcolor="ff8888"|act
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|PatientTherapieWuensche
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|
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|0..*
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|O
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|
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|-
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|5
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|bgcolor="ff8888"|act
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|M
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|OBS
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|-
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|5
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|bgcolor="ff8888"|act
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|@moodCode
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|M
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|EVN
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|-
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|5
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|bgcolor="ff8888"|act
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|code
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|CD CWE
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|0..1
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|O
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|
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|-
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|5
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|
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|-
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|bgcolor="ff8888"|act
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|value
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|5
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|-
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|5
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|CD CWE
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|0..1
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|O
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|
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|-
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|O
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|
 +
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|}
  
 
===Beispiel===
 
===Beispiel===

Version vom 3. März 2014, 15:48 Uhr

Section: Aufnahme

Template-Metadaten
Template-Typ Section
Template ID -
generischeres Template -
genutztes Templates -
nutzende Templates -
abgeleitete Templates -
Schwester-Templates -
generelle Beschreibung Aufnahme
allg. Erläuterung Sektion Aufnahme
Verhältnis zu IHE neu
Ballotierungsstatus in Abstimmung
Erweiterbarkeit offen


Alle Aufnahmen (Erstaufnahme, Notaufnahme, geplante Wiederaufnahme etc.) werden in der Sektion „Aufnahme“ festgehalten. Über den Abschnitt Aufnahme werden relevante alle relevanten Daten der Aufnahme des Patienten in ein System der palliativen Versorgung festgehalten.


Aufnahme cda.png

Lvl RIM Name DT Kard Conf Beschreibung
1 act Aufnahme null null
1 act @classCode CS CNE 1..1 M DOCSECT
1 act @moodCode CS CNE 1..1 M EVN
1 act code CD CWE 0..1 O
1 rel entry 0..* O
2 rel @typeCode CS CNE 1..1 M
2 act Aufnahme 0..* O
3 act @classCode CS CNE 1..1 M OBS
3 act @moodCode CS CNE 1..1 M EVN
3 act code CD CWE 1..1 O
3 act effectiveTime TS 1..1 R
3 act effectiveTime TS 1..1 R
3 part participant 1..1 O
3 rel entry 0..* O
4 rel @typeCode CS CNE 1..1 M
4 act Mobilität 1..1 O
5 act @classCode CS CNE 1..1 M OBS
5 act @moodCode CS CNE 1..1 M EVN
5 act code CD CWE 0..1 O
5 act value ANY CWE 0..1 O
3 rel entry 0..1 O
4 rel @typeCode CS CNE 1..1 M
4 act Prognose 0..* O
5 act @classCode CS CNE 1..1 M OBS
5 act @moodCode CS CNE 1..1 M EVN
5 act code CD CWE 0..1 O
5 act text ED 0..1 O
5 act value ANY CWE 0..1 O
3 rel entry 0..1 O
4 rel @typeCode CS CNE 1..1 M
4 act ErkrankungsrelevanteBehandlung 0..* O
5 act @classCode CS CNE 1..1 M PROC
5 act @moodCode CS CNE 1..1 M EVN
5 act code CD CWE 0..1 O
5 act text ED 0..1 O
3 rel entry 0..1 O
4 rel @typeCode CS CNE 1..1 M
4 act BesondererAufwandMit 0..* O
5 act @classCode CS CNE 1..1 M OBS
5 act @moodCode CS CNE 1..1 M EVN
5 act code CD CWE 0..1 O
5 act text ED 0..1 O
5 act value ANY CWE 0..1 O
3 rel entry 0..1 O
4 rel @typeCode CS CNE 1..1 M
4 act PatientTherapieWuensche 0..* O
5 act @classCode CS CNE 1..1 M OBS
5 act @moodCode CS CNE 1..1 M EVN
5 act code CD CWE 0..1 O
5 act text ED 0..1 O
5 act value ANY CWE 0..1 O
3 rel entry 0..1 O
4 rel @typeCode CS CNE 1..1 M
4 act Behandlungsziel 0..* O
5 act @classCode CS CNE 1..1 M OBS
5 act @moodCode CS CNE 1..1 M EVN
5 act code CD CWE 0..1 O
5 act text ED 0..1 O
5 act value ANY CWE 0..1 O

Beispiel

<section>
	<code code="52536-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Admission Information"/>
	<entry typeCode="DRIV">
		<observation classCode="OBS" moodCode="EVN">
			<code xsi:type="CD" code="3.0" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="Aufnahme"/>
			<effectiveTime value="20140201"/>
			<value xsi:type="CD" code="1" codeSystem="1.2.276.0.76.3.1.81.4.6.2" codeSystemName="Zuweisung als" displayName="Geplante Erstaufnahme"/>
			<participant typeCode="REF">
				<participantRole classCode="CAREGIVER">
					<id extension="123 " root="xxx " />
					<playingEntity>								
						<name>
							<given>Notarzt Dr. Max</given>
							<family>Mustermann</family>
						</name>
					</playingEntity>
				</participantRole>
			</participant>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<code xsi:type="CD" code="xxx" codeSystem="xxx" codeSystemName="xxx" displayName="Mobilität"/>
					<value xsi:type="CD" code="4" codeSystem="1.2.276.0.76.3.1.81.4.6.3" codeSystemName="Mobilitaet" displayName="Nachtstuhl"/>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<code xsi:type="CD" code="3.1" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="Prognose"/>
					<text>
						Text bwz. Kommentare, falls vorhanden
					</text>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<code xsi:type="CD" code="3.4" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="Besonderer Aufwand mit"/>
					<text>
						Text bzw. Kommentare, falls vorhanden
					</text>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<code xsi:type="CD" code="3.5" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="PatientenTherapieWuensche"/>
					<text>
						Text bzw. Kommentare, falls vorhanden
					</text>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<code xsi:type="CD" code="3.6" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="Behandlungsziel"/>
					<text>
						Text bzw. Kommentare, falls vorhanden
					</text>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<procedure classCode="PROC" moodCode="EVN">
					<code xsi:type="CD" code="3.3" codeSystem="1.2.276.0.76.3.1.81.4.6.0" codeSystemName="Palliativinhalte" displayName="ErkrankungsrelevanteBehandlung"/>
					<text>
						Text bzw. Kommentare, falls vorhanden
					</text>
				</procedure>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<!-- Neuer Eintrag -->
			</entryRelationship>
		</observation>
	</entry>
</section>
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