Änderungen

<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.40.0.34.6.0.11.1.32</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2019‑08‑08 12:42:14</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Entwurf</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;">2019</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">atcdabbr_header_DocumentationOfServiceEvent_eImpfpass</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Documentation Of Service Event - e-Impfpass</td></tr><td style="text-align: left;" colspan="4"><table class="treetable" id="templateDescTable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Beschreibung</td></tr><tr><td><div><span style="color: rgb(51, 51, 51); font-family: Verdana, Arial, sans-serif; font-size: 12px;">Dokumentation der Gesundheitsdienstleistung. </span><br /><br /span><span style="color: rgb(51, 51, 51); font-family: Verdana, Arial, sans-serif; font-size: 12px;"><br />Mit der Assoziation documentationOf/serviceEvent wird die eigentliche Gesundheitsdienstleistung repräsentiert, die in dem Dokument dokumentiert wird (z.B. eine Koloskopie, Appendektomie, etc.). Dies ist in engem Zusammenhang mit dem Dokumententyp zu sehen, der in ClinicalDocument/code wiedergegeben ist. Mit der documentationOf Beziehung kann die dokumentierte Gesundheitsdienstleistung näher spezifiziert werden. Dies darf natürlich nicht im Widerspruch zum Dokumententyp stehen.</span><br /><br /><br /span><b style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51); font-variant-numeric: inherit; font-variant-east-asian: inherit; font-stretch: inherit; line-height: inherit;"><br />↔ Hinweis zum XDS-Mapping: <br /b><br /b><span style="color: rgb(51, 51, 51); font-family: Verdana, Arial, sans-serif; font-size: 12px;">Da diese </span><b style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51); font-variant-numeric: inherit; font-variant-east-asian: inherit; font-stretch: inherit; line-height: inherit;">Informationen in die XDS-Metadaten übernommen</b><span style="color: rgb(51, 51, 51); font-family: Verdana, Arial, sans-serif; font-size: 12px;"> werden, ergeben sich folgende Implikationen: </span><br /><ul style="font-family: Verdana, Arial, sans-serif; font-size: 12px; color: rgb(51, 51, 51);"><li>Es <b style="font-family: inherit; font-size: inherit; color: inherit; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: inherit;">SOLL mindestens eine Gesundheitsdienstleistung</b> als documentationOf/serviceEvent-Element angegeben werden<br /> </li><li>Es <b style="font-family: inherit; font-size: inherit; color: inherit; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: inherit;">können beliebig viele</b> weitere Gesundheitsdienstleistungen als weitere documentationOf/serviceEvent-Elemente angegeben werden.<br /> </li><li>Die serviceEvents sind die einzigen medizinischen Informationen zum Dokument im XDS-Dokumentenregister</li><li>Können daher als <b style="font-family: inherit; font-size: inherit; color: inherit; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: inherit;">Such-/Filterkriterium</b> verwendet werden und scheinen ggf. in den Ergebnissen der Suchabfragen auf</li><li>Die Zeitangaben des <b style="font-family: inherit; font-size: inherit; color: inherit; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: inherit;">ersten </b>documentationOf/serviceEvent-Elements werden in die Dokument-Metadaten übernommen</li><li>Die ServiceEvents stellen eine wertvolle Information zum Suchen und Filtern in den Dokument-Metadaten dar! </li></ul></div></td></tr></table></td><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Header 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">Geschlossen (nur definierte Elemente sind erlaubt)</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beziehung</th><td style="text-align: left;" colspan="3">Spezialisierung: Template 1.2.40.0.34.6.0.11.1.17 <i>Documentation Of Service Event </i> (2019‑03‑14 15:08:34) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div></span><br />Version: Template 1.2.40.0.34.11.20010 <i> </i> (2017‑07‑21 11:18:58) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">?</div></span><br />Version: Template 1.2.40.0.34.11.20010 <i>HeaderServiceEvent </i> (2011‑12‑19) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">elgabbr-</div></span></td></tr><tr class="explabel " style="vertical-align: top;"><td style="width: 20em; text-align: left;">Beispiel</td><td colspan="3" class="explabelgreen"><table class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable"><span class="expcaption">Strukturbeispiel Koloskopie</span></td></tr><tr><td><tt><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">documentationOf</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">DOC</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">serviceEvent</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">PCPR</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">code</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">41000179103</span><span class="ppsign">"</span> <span class="ppattribute">codeSystem</span><span class="ppsign">="</span><span class="ppcontent">2.16.840.1.113883.6.96</span><span class="ppsign">"</span> <span class="ppattribute">codeSystemName</span><span class="ppsign">="</span><span class="ppcontent">SNOMED CT</span><span class="ppsign">"</span> <span class="ppattribute">displayName</span><span class="ppsign">="</span><span class="ppcontent">Immunization record (record artifact)</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">    <span class="ppsign">&lt;</span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">low</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20190808130209+0200</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">      <span class="ppsign">&lt;</span><span class="ppelement">high</span> <span class="ppattribute">value</span><span class="ppsign">="</span><span class="ppcontent">20190808130209+0200</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span>    <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">effectiveTime</span><span class="ppsign">&gt;</span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">serviceEvent</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">documentationOf</span><span class="ppsign">&gt;</span></span></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="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:documentationOf<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>Komponente für die Gesundheitsdienstleistung.<br />

</td><td style="background-color: #FFEEEE;"><span title="">(atc...ass)</span></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><strong>@classCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">PCPR</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><strong>@moodCode<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " 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><strong>hl7:code<br /></strong></tt></td></tr></table></td><td><strong>CE</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td>Code der Gesundheitsdienstleistung, fixer Wert 41000179103.<br /><br /><span lang="DE-AT" style=""> </span><div style=""> <span style="font-family: Arial, sans-serif; font-size: 13.3333px;"> <b>↔ Hinweis zum XDS-Mapping: </b></span></div><div style=""><span style="font-family: Arial, sans-serif; font-size: 13.3333px;">Dieses Element wird ins XDS-Attribut eventCodeList gemappt. </span></div>

</span></td><td style="background-color: #FFEEEE;"><span title="">(atc...ass)</span></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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@code<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">41000179103</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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td>oid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">2.16.840.1.113883.6.96</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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@codeSystemName<br /></strong></tt></td></tr></table></td><td>st</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">SNOMED CT</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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@displayName<br /></strong></tt></td></tr></table></td><td>st</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">Immunization record (record artifact)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " 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><strong>hl7:effectiveTime<br /></strong></tt></td></tr></table></td><td><strong>IVL_TS</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td><div> <div>Zeitraum der Gesundheitsdienstleistung, </div> <div> <b> <br />↔ Hinweis zum XDS-Mapping: </b> </div> <div>Dieses Element wird in die XDS-Attribute <i>serviceStartTime </i>und <i>serviceStopTime </i>gemappt. </div> <div>Für die automatisierte Datenübernahme aus dem CDA-Dokument in die XDS-Dokumentmetadaten ist stets ein Zeitintervall anzugeben.</div> <div> <br /> </div> <div>ACHTUNG: Die Zeitangaben der jeweils ersten Gesundheitsdienstleistung (erstes documentationOf/serviceEvent-Element) werden in die Dokument-Metadaten übernommen! </div> <div>Die Bedeutung der Dokument-Metadaten-Elemente lautet daher wie folgt: </div> <div>serviceStartTime: Beginn des ersten documentationOf/serviceEvent-Elements</div> <div>serviceStopTime: Ende des ersten documentationOf/serviceEvent-Elements </div></div> </td><td style="background-color: #FFEEEE;"><span title="">(atc...ass)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:low<br /></strong></tt></td></tr></table></td><td><strong>TS.AT.TZ</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(atc...ass)</span></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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@nullFlavor<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">UNK</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"><b>Für  "Update Immunisierungsstatus"</b><br />Zeitpunkt des Behandlungsbeginns (aktueller Besuch).<br /><br /><b>Für "Kompletter Immunisierungsstatus":</b><br />Zeitpunkt des <i>ältesten </i>effectiveTime aus:<br /> <ul> <li>"Immunization Entry", templateId 1.2.40.0.34.6.0.11.3.1,<br />substanceAdministration/effectiveTime<br />

</li> <li>"Impfrelevante Erkrankungen Problem Entry",<br />templateId 1.2.40.0.34.6.0.11.3.9,<br />observation/effectiveTime/low</li></ul> </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:high<br /></strong></tt></td></tr></table></td><td><strong>TS.AT.TZ</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(atc...ass)</span></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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@nullFlavor<br /></strong></tt></td></tr></table></td><td>cs</td><td><span><strong>0 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">UNK</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"><div> <b>Für  "Update Immunisierungsstatus"</b> <br />Zeitpunkt des Behandlungsendes (aktuelle Behandlung, muss sich von Behandlungsbeginn unterscheiden)<br /> <br /> <b>Für "Kompletter Immunisierungsstatus":</b> <br /></div><div>Zeitpunkt des <i>jüngsten </i>effectiveTime aus:<br /></div> <ul> <li>"Immunization Entry", templateId 1.2.40.0.34.6.0.11.3.1,<br />substanceAdministration/effectiveTime<br />

</li> <li>"Impfrelevante Erkrankungen Problem Entry",<br />templateId 1.2.40.0.34.6.0.11.3.9,<br />observation/effectiveTime/high</li></ul>