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1.2.40.0.34.6.0.11.1.33/static-2019-11-22T102108

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<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;">1.2.40.0.34.6.0.11.1.33 <div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">elgagab-</div></td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2019‑11‑22 10:21:08</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;">elgagab_header_DocumentationOfServiceEventOutpatientReport</td><th style="width: 20em; text-align: left;">Anzeigename</th><td style="text-align: left;">Documentation Of Service Event - Outpatient Report</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>Dokumentation der Gesundheitsdienstleistung.

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.

WICHTIG: Im Zuge der Einstellung eines Ambulanzbefundes wird durch die XDS-Metadaten dargestellt welche Sektionen in gegenständlichen Ambulanzbefund enthalten sind und in welcher Ausprägung (maschinenlesbar oder nicht). Daher MUSS der jeweilige section/code als serviceEvent/code als auch die section/templateId (OID Bereich: 1.2.40.0.34.6.0.11.2.X) der Sektion als serviceEvent/id@root-Element angegeben werden.

<li>Die Zeitangaben des ersten 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;">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 1 Template</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</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;">1.2.40.0.34.6.0.11.9.22</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Assigned Entity (2019)</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">Spezialisierung: Template 1.2.40.0.34.6.0.11.1.17 Documentation Of Service Event (2019‑03‑14 15:08:34) <div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div> Version: Template 1.2.40.0.34.11.20010 (2017‑07‑21 11:18:58) <div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">?</div> Version: Template 1.2.40.0.34.11.20010 HeaderServiceEvent (2011‑12‑19) <div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">elgabbr-</div></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">Strukturbeispiel Koloskopie</td></tr><tr><td><tt><documentationOf typeCode="DOC"> <serviceEvent classCode="ACT" moodCode="EVN"> <~~code~~id ~~code~~root="~~KOL~~1.2.40.0.34.6.0.11.2.1" ~~displayName~~/=">~~Koloskopie~~ <code ~~codeSystem~~code="~~2.16.840.1.2.3.4.5.~~11369-6~~.7.8.9~~" ~~codeSystemName~~displayName="~~Name des Codesystems~~HISTORY OF IMMUNIZATIONS"/codeSystem~~>~~=" 2.16.840.1.113883.6.1~~<~~"~~effectiveTime~~codeSystemName~~>~~="</span~~> ~~<~~LOINC~~low~~" ~~value~~/=">~~20190611102209+02:00~~ "</effectiveTime> <~~high~~low value="~~20190611132209~~20190611102209+02:00"/> </high~~effectiveTime~~value~~>~~=" 20190611132209+02:00~~<<~~"~~performer~~/ ~~typeCode~~> ="</~~PRF~~"effectiveTime> <~~assignedEntity~~performer~~>~~typeCode</span~~> ="PRF" &ltgt;~~!-- include template 1.2.40.0.34.6.0.11.9.22 'Assigned Entity' (dynamic) 1..1 M --><br~~ </spanstyle="display: block;" class="explrendered"> <~~/~~assignedEntity> <spanstyle="display: block;"> <~~/</~~!-- include template 1.2.40.0.34.6.0.11.9.22 'Assigned Entity' (dynamic) 1..1 M --> </~~performer~~assignedEntity> </~~serviceEvent~~performer> </~~documentationOf~~serviceEvent><~~/tt~~span class="ppsign"><</~~td>~~</trspan><~~/table~~span class="ppnamespace"></tdspan><~~/tr><tr~~ span class="~~explabel " style="vertical-align: top;~~ppelement">documentationOf<~~td style~~span class="~~width: 20em; text-align: left;~~ppsign">~~Beispiel~~></tt></td></tr></table></td ~~colspan~~></tr><tr class="3explabel " ~~class~~style="~~explabelgreen~~vertical-align: top;"><~~table class~~td style=~~"treetable~~"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">Strukturbeispiel Hämatologie</td></tr><tr><td><tt><documentationOf typeCode="DOC"> <serviceEvent classCode="ACT" moodCode="EVN"> <~~code~~id ~~code~~root="~~300~~1.2.40.0.34.6.0.11.2.53"/> <code code="11369-6" displayName="History of Immunization Narrative" codeSystem=" ~~displayName~~2.16.840.1.113883.6.1="~~Hämatologie~~codeSystemName=" ~~codeSystem~~LOINC="~~1.2.40.0.34.5.11~~/"> ~~codeSystemName~~=~~display: block;"~~<span~~ class="~~ppcontent~~explrendered">~~ELGA_LaborparameterErgaenzung~~ "</effectiveTime> <~~effectiveTime> <lowlow value="20190611102209+02:00"/> <high value="20190611132209+02:00"/> </effectiveTime> <performer typeCode="PRF"> <time> <low nullFlavor="UNK" value="20190611132209+02:00"/> <high nullFlavor="UNK" value="20190611132209+02:00"/> </time> <assignedEntity>  </assignedEntity> </performer> </serviceEvent></documentationOf></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>hl7:documentationOf </tt></td></tr></table></td><td></td><td></td><td></td><td>Komponente für die Gesundheitsdienstleistung. </td><td style="background-color: #FFEEEE;">(elg...ort)</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: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">DOC</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:Treetree.png|16px]]</td><td><tt>hl7:serviceEvent </tt></td></tr></table></td><td></td><td>1 … 1</td><td>M</td><td>Die serviceEvents in den ELGA Ambulanzbefunden MÜSSEN die section/code-Element wiedergeben als auch die section/template-id. Diese Information werden über eine Mapping-Vorschrift in die XDS-Metadaten übernommen und ermöglichen einem ELGA-Teilnehmer zu erkennen welche Sektionen beinhalten sind und in welchem Kodierungsgrad diese vorliegen. Daher muss für jede Sektion, welche medizinische Information enthält (Ausnahmen sind "Brieftext" und "Abschließende Bemerkungen"), ein documentationOf/serviceEvent codiert werden.</td><td style="background-color: #FFEEEE;">(elg...ort)</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>@classCode </tt></td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">ACT</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>@moodCode </tt></td></tr></table></td><td>cs</td><td>0 … 1</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>hl7:id </tt></td></tr></table></td><td>II</td><td>1 … 1</td><td>M</td><td></td><td style="background-color: #FFEEEE;">(elg...ort)</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>@extension </tt></td></tr></table></td><td>st</td><td>0</td><td>NP</td><td style="vertical-align: top;" colspan="2">NP/nicht anwesend</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>@root </tt></td></tr></table></td><td>uid</td><td>1 … 1</td><td>R</td><td style="vertical-align: top;" colspan="2">In das serviceEvent/id@root Attribute MUSS die section/templateId@root geschrieben werden. Im Falle von mehreren section/templateIds MUSS jene gewählt werden welche in dem OID-Bereich 1.2.40.0.34.6.0.11.2.X zu finden ist.</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>hl7:code </tt></td></tr></table></td><td>CE (extensible)</td><td>1 … 1</td><td>R</td><td>Der serviceEvent/code MUSS den section/code wiedergeben.</td><td style="background-color: #FFEEEE;">(elg...ort)</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>@code </tt></td></tr></table></td><td>cs</td><td>1 … 1</td><td>R</td><td style="vertical-align: top;" colspan="2"></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>@codeSystem </tt></td></tr></table></td><td>oid</td><td>1 … 1</td><td>R</td><td style="vertical-align: top;" colspan="2"></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>@codeSystemName </tt></td></tr></table></td><td>st</td><td>0 … 1</td><td> </td><td style="vertical-align: top;" colspan="2"></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>@displayName </tt></td></tr></table></td><td>st</td><td>1 … 1</td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code sollte gewählt werden aus dem Value Set 1.2.40.0.34.10.360 elgagab_SectionsServiceEvent_VS (DYNAMIC)</td></tr></table></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>hl7:effectiveTime </tt></td></tr></table></td><td>IVL_TS</td><td>1 … 1</td><td>M</td><td><div>Zeitraum der Gesundheitsdienstleistung, Die semantische Bedeutung dieser Zeitpunkte wird in den speziellen Implementierungsleitfäden festgelegt.

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