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1.2.40.0.34.11.13.2.2/static-2017-01-26T135054

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<div>Status post-Diagnosen können ebenfalls in dieser Sektion erfasst werden, sofern sie für weitere Behandler relevant sind.

</div>

</div>Gesundheitsprobleme & Risiken werden mit ihrem Status und Datum, sofern bekannt, dokumentiert, weiters mit dem Datum der Erfassung der Diagnose.</div></td></tr></table></td><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Kontext</th><td style="text-align: left;" colspan="3">Elternknoten des Template-Element mit Id 1.2.40.0.34.11.13.2.2</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Section level template</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Offen/Geschlossen</th><td style="text-align: left;" colspan="3">Offen (auch andere als die definierten Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Benutzt von / Benutzt</th><td style="text-align: left;" colspan="3"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt von 0 Transactions und 1 Template, Benutzt 3 Templates</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" style="background: transparent;"><tr><th style="width: 20%; text-align: left;">Benutzt von</th><th style="width: 1%; text-align: left;"> als </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.2.40.0.34.11.13</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] CDA ELGA Patient Summary (0.1)</td><td style="text-align: left;">2016‑08‑30 16:19:25</td></tr><tr><th style="width: 20%; text-align: left;">Benutzt</th><th style="width: 1%; text-align: left;"> als </th><th style="width: 60%; text-align: left;">Name</th><th style="width: 19%; text-align: left;">Version</th></tr><tr><td style="text-align: left;">1.2.40.0.34.11.13.3.16</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Author (Body) PS</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.11.13.3.20</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Informant (Body) PS (0.1)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.11.13.3.6</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Gesundheitsproblem Bedenken Entry (0.2)</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></td></tr></table></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beziehung</th><td style="text-align: left;" colspan="3">Abgeleitet: Template 1.2.40.0.34.11.2.2.3 (2015‑10‑15)</td></tr><tr class="explabel" style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelblue"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable">Strukturbeispiel</td></tr><tr><td><tt><section> <templateId root="1.2.40.0.34.11.13.2.2"/> <code code="11450-4" displayName="Problem list" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Gesundheitsprobleme und Risiken</title> <text/> <author>  </author> <informant>  </informant> <entry typeCode="DRIV">  </entry></section></tt></td></tr></table></td></tr><tr class="explabel" style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelblue"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable">Vollständig</td></tr><tr><td><tt><section> <templateId root="1.2.40.0.34.11.13.2.2"/> <code code="11450-4" codeSystem="2.16.840.1.113883.6.1"/> <title>Gesundheitsprobleme und Risiken</title> <text> <table> <tr> <th>Code</th> <th>Problem</th> <th>Zusatzinformation</th> </tr> <tr> <td ID="code1">ICD-10: N95.1</td> <td ID="prob1">Hitzewallung (postmenopausal)</td> <td ID="doc1">Quelle: Ärztlicher Entlassungsbrief 2015-03-18 Amadeus Spital Salzburg</td> </tr> <tr> <td ID="code2">ICD-O: 8500/3</td> <td ID="prob2">Invasiv duktales Karzinom der Brustdrüse, Stage II</td> <td> <ul> <li>Bekannt seit 2015-02</li> <li>wird noch beobachtet</li> <li ID="sev2">Schweregrad: schwerwiegend</li> <li ID="cert2">Diagnosesicherheit: bestätigt</li> <li ID="status2">klinischer Status: ohne Anzeichen eines erneuten Auftretens nach Behandlung</li> <li>Author: Dr.Isabella Stern</li> <li ID="doc2">Quelle: Ärztlicher Entlassungsbrief 2015-03-18 Amadeus Spital Salzburg</li> </ul> </td> </tr> <tr> <td ID="code3">ICD-10: K21.0</td> <td ID="prob3">Refluxösophagitis II</td> <td/> </tr> <tr> <td ID="code4">ICD-10: Z92.1</td> <td ID="prob4">Antikoaguliert mit Sintrom</td> <td/> </tr> <tr> <td/> <td ID="prob5">Oberbauchschmerzen, Übelkeit (? Duodenitis)</td> <td>Informant: Patientangabe</td> </tr> </table> </text> <entry typeCode="DRIV">  <act> <templateId root="1.2.40.0.34.11.13.3.6"/> <id root="1.2.3.999" extension="--example only--"/> <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/> <statusCode code="active"/> <effectiveTime> <low nullFlavor="UNK"/> </effectiveTime> <entryRelationship typeCode="SUBJ" inversionInd="false">  <observation> <templateId root="1.2.40.0.34.11.13.3.7"/> <id root="1.2.3.999" extension="--example only--"/>  <code code="75322-8" codeSystem="2.16.840.1.113883.5.6" displayName="Complaint" codeSystemName="LOINC"/> <statusCode code="completed"/> <effectiveTime> <low nullFlavor="UNK"/> </effectiveTime> <value hl7:type="CD" code="N95.1" displayName="Zustände im Zusammenhang mit der Menopause und dem Klimakterium" codeSystem="1.2.40.0.34.5.171" codeSystemName="ICD-10 BMG 2017"> <originalText> <reference value="#prob1"/> </originalText> <translation code="X11" displayName="Menopausale Symptome/Beschwerden" codeSystem="1.2.40.0.34.5.175" codeSystemName="ICPC2"/> </value> </observation> </entryRelationship> <reference> <externalDocument classCode="DOC" moodCode="EVN">  <id root="1.2.3.999" extension="--example only--"/>  <code code="11490-0" displayName="Physician Discharge summary" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <text> <reference value="#doc1"/> </text> </externalDocument> </reference> </act> </entry> <entry typeCode="DRIV">  <act> <templateId root="1.2.40.0.34.11.13.3.6"/> <id root="1.2.3.999" extension="--example only--"/> <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/> <statusCode code="active"/> <effectiveTime> <low nullFlavor="UNK"/> </effectiveTime> <author typeCode="AUT" contextControlCode="OP">  <time value="UNK"/> <assignedAuthor classCode="ASSIGNED"> <id root="1.2.3.999" extension="--example only--"/> <code code="107" displayName="Fachärztin/Facharzt für Chirurgie" codeSystem="1.2.40.0.34.5.160" codeSystemName="ELGA_Fachaerzte"/> <assignedPerson classCode="PSN" determinerCode="INSTANCE"> <name> <prefix qualifier="AC">Univ.Prof. Dr.</prefix> <given>Isabella</given> <family>Stern</family> </name> </assignedPerson> </assignedAuthor> </author> <entryRelationship typeCode="SUBJ" inversionInd="false">  <observation> <templateId root="1.2.40.0.34.11.13.3.7"/> <id root="1.2.3.999" extension="--example only--"/> <code code="29308-4" codeSystem="2.16.840.1.113883.6.1" displayName="Diagnosis" codeSystemName="LOINC"/> <statusCode code="completed"/> <effectiveTime> <low value="20150200"/> </effectiveTime> <value hl7:type="CD" code="8500/3" displayName="Invasives duktales Karzinom o.n.A." codeSystem="2.16.840.1.113883.6.43.1" codeSystemName="icd-o-3"> <originalText> <reference value="#prob2"/> </originalText> <translation/> </value> <entryRelationship typeCode="SUBJ" inversionInd="true"> <observation classCode="OBS" moodCode="EVN">  <templateId root="1.2.40.0.34.11.13.3.21"/> <id root="1.2.3.999" extension="--example only--"/> <code code="SEV"/> <statusCode code="completed"/>  <value hl7:type="CD" code="24484000" displayName="Severe" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"> <originalText> <reference value="#sev2"/> </originalText> </value> </observation> </entryRelationship> <entryRelationship typeCode="SUBJ" inversionInd="true"> <observation classCode="OBS" moodCode="EVN">  <templateId root="1.2.40.0.34.11.13.3.19"/> <code code="NEW-LOINC-CERTAINTY" codeSystem="2.16.840.1.113883.6.1"/> <statusCode code="completed"/>  <value hl7:type="CD" code="confirmed" displayName="confirmed" codeSystem="2.16.840.1.113883.4.642.3.115" codeSystemName="AllergyIntoleranceVerificationStatus"> <originalText> <reference value="#cert2"/> </originalText> </value> </observation> </entryRelationship> <entryRelationship typeCode="REFR" inversionInd="false">  <observation classCode="OBS" moodCode="EVN"> <templateId root=" 1.2.40.0.34.11.13.3.13"/> <code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <statusCode code="completed"/>  <value hl7:type="CD" code="remission" displayName="Remission" codeSystem="2.16.840.1.113883.4.642.3.155" codeSystemName="Condition Clinical Status Codes"> <originalText> <reference value="#status2"/> </originalText> </value> </observation> </entryRelationship> </observation> </entryRelationship> <reference> <externalDocument classCode="DOC" moodCode="EVN">  <id root="1.2.3.999" extension="--example only--"/>  <code code="11490-0" displayName="Physician Discharge summary" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <text> <reference value="#doc2"/> </text> </externalDocument> </reference> </act> </entry> <entry typeCode="DRIV">  <act> <templateId root="1.2.40.0.34.11.13.3.6"/> <id root="1.2.3.999" extension="--example only--"/> <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/> <statusCode code="active"/> <effectiveTime> <low nullFlavor="UNK"/> </effectiveTime> <entryRelationship typeCode="SUBJ" inversionInd="false">  <observation> <templateId root="1.2.40.0.34.11.13.3.7"/> <id root="1.2.3.999" extension="--example only--"/> <code code="75322-8" codeSystem="2.16.840.1.113883.6.1" displayName="Complaint" codeSystemName="LOINC"/> <statusCode code="completed"/> <effectiveTime> <low nullFlavor="UNK"/> </effectiveTime> <value hl7:type="CD" code="K21.0" displayName="Gastroösophageale Refluxkrankheit mit Ösophagitis" codeSystem="1.2.40.0.34.5.171" codeSystemName="ICD-10 BMG 2017"> <originalText> <reference value="#prob3"/> </originalText> </value> </observation> </entryRelationship> </act> </entry> <entry typeCode="DRIV">  <act> <templateId root="1.2.40.0.34.11.13.3.6"/> <id root="1.2.3.999" extension="--example only--"/> <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/> <statusCode code="active"/> <effectiveTime> <low nullFlavor="UNK"/> </effectiveTime> <entryRelationship typeCode="SUBJ" inversionInd="false">  <observation> <templateId root="1.2.40.0.34.11.13.3.7"/> <id root="1.2.3.999" extension="--example only--"/> <code code="75323-6" codeSystem=" 2.16.840.1.113883.6.1" displayName="Condition" codeSystemName="LOINC"/> <statusCode code="completed"/> <effectiveTime> <low nullFlavor="UNK"/> </effectiveTime> <value hl7:type="CD" code="Z92.1" displayName="Dauertherapie (gegenwärtig) mit Antikoagulanzien in der Eigenanamnese" codeSystem="1.2.40.0.34.5.171" codeSystemName="ICD-10 BMG 2017"> <originalText> <reference value="#prob4"/> </originalText> <translation/> </value> </observation> </entryRelationship> </act> </entry> <entry typeCode="DRIV">  <act> <templateId root="1.2.40.0.34.11.13.3.6"/> <id root="1.2.3.999" extension="--example only--"/> <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/> <statusCode code="active"/> <effectiveTime> <low nullFlavor="UNK"/> </effectiveTime> <informant>  <relatedEntity classCode="PRS"> <code code="SELF" displayName="self" codeSystem="1.2.40.0.34.10.17" codeSystemName="ELGA_PersonalRelationship"/> </relatedEntity> </informant> <entryRelationship typeCode="SUBJ" inversionInd="false">  <observation> <templateId root="1.2.40.0.34.11.13.3.7"/> <id root="1.2.3.999" extension="--example only--"/> <code code="75322-8" codeSystem="2.16.840.1.113883.6.1" displayName="Complaint" codeSystemName="LOINC"/> <statusCode code="completed"/> <effectiveTime> <low nullFlavor="UNK"/> </effectiveTime> <value hl7:type="CD" nullFlavor="NI"> <originalText> <reference value="#prob5"/> </originalText> </value> </observation> </entryRelationship> </act> </entry></section></tt></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr><th style="width: 30%; text-align: left;">Item</th><th style="width: 2em; text-align: left;">DT</th><th style="width: 2em; text-align: left;">Kard</th><th style="width: 2em; text-align: left;">Konf</th><th style="text-align: left;">Beschreibung</th><th style="width: 2em; text-align: left;">Label</th></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td><tt>hl7:section </tt></td></tr></table></td><td></td><td>1 … 1</td><td>R</td><td></td><td style="background-color: #FFEEEE;">(Ges...ken)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt>hl7:templateId </tt></td></tr></table></td><td>II</td><td>1 … 1</td><td>M</td><td></td><td style="background-color: #FFEEEE;">(Ges...ken)</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt>@root </tt></td></tr></table></td><td>uid</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.40.0.34.11.13.2.2</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt>hl7:code </tt></td></tr></table></td><td>CE ~~CWE~~ (extensible)</td><td>1 … 1</td><td>M</td><td></td><td style="background-color: #FFEEEE;">(Ges...ken)</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt>@code </tt></td></tr></table></td><td rowspan="4" class="conf">CONF</td><td>1 … 1</td><td>F</td><td colspan="2">11450-4</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt>@codeSystem </tt></td></tr></table></td><td>1 … 1</td><td>F</td><td colspan="2">2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt>@codeSystemName </tt></td></tr></table></td><td>1 … 1</td><td>F</td><td colspan="2">LOINC</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt>@displayName </tt></td></tr></table></td><td>1 … 1</td><td>F</td><td colspan="2">Problem list</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt>hl7:title </tt></td></tr></table></td><td>ST</td><td>1 … 1</td><td>M</td><td></td><td style="background-color: #FFEEEE;">(Ges...ken)</td></tr><tr style="vertical-align: top; background-color: #FAFAD2;"><td style="background-color: white;" colspan="1"> </td><td class="conf">Constraint</td><td style="background-color: #FAFAD2;" colspan="4">Fixer Wert: Gesundheitsprobleme und Risiken</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt>hl7:text </tt></td></tr></table></td><td></td><td>1 … 1</td><td>M</td><td><div>Dieses Element enthält alle zum Zeitpunkt der Erstellung bekannten relevanten Gesundheitsprobleme der Patienten. Dies umfasst akute Diagnosen, Dauerdiagnosen, Infektionskrankheiten sowie Risiken in tabellarischer Darstellung.

</div>

<div>Sie werden mit ihrem Status und Datum, sofern bekannt, dokumentiert, weiters mit dem Datum der Erfassung der Diagnose.

</div></td><td style="background-color: #FFEEEE;">(Ges...ken)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt>hl7:author </tt></td></tr></table></td><td></td><td>0 … *</td><td></td><td>Autor der enthaltenen Information (GDA) Beinhaltet 1.2.40.0.34.11.13.3.16 Author (Body) PS (DYNAMIC)</td><td style="background-color: #FFEEEE;">(Ges...ken)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt>hl7:informant </tt></td></tr></table></td><td></td><td>0 … *</td><td></td><td><div>Quelle für die enthaltene Information</div>

<div>Name der Person und ihre Beziehung zum Patienten (Patient oder Angehöriger, Auskunftsperson - nicht-GDA)</div> Beinhaltet 1.2.40.0.34.11.13.3.20 Informant (Body) PS (DYNAMIC)</td><td style="background-color: #FFEEEE;">(Ges...ken)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt>hl7:entry </tt></td></tr></table></td><td></td><td>1 … *</td><td>M</td><td>Beinhaltet 1.2.40.0.34.11.13.3.6 Gesundheitsproblem Bedenken Entry (DYNAMIC)</td><td style="background-color: #FFEEEE;">(Ges...ken)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo [hl7:act [hl7:templateId [@root='1.2.40.0.34.11.13.3.6']]]</td></tr></table></td><td></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt>@typeCode </tt></td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">DRIV</td></tr></table></td></tr></table>

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