Änderungen

1.2.40.0.34.6.0.11.3.6/static-2020-11-06T100841

8 Bytes hinzugefügt, 07:22, 13. Mai 2021

Automatic ADBot page (ef7c4089b68460697c831300330b6cf6e2d3b82c)

<table xmlns="http://www.w3.org/1999/xhtml" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Id</th><td style="text-align: left;">1.2.40.0.34.6.0.11.3.6 <div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div></td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2020‑11‑06 10:08:41<div>Andere Versionen mit dieser Id:<ul><li>[[File:Kblank.png|14px]] atcdabbr_entry_Problem vom 2021‑02‑19 12:55:41</li><li>[[File:Kblank.png|14px]] atcdabbr_entry_Problem vom 2019‑01‑18 09:59:00</li></ul></div></td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kgreen.png|14px]] Aktiv</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;">2020.1</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">atcdabbr_entry_Problem</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">Problem Entry</td></tr><td style="text-align: left;" colspan="4"><table id="templateDescTable" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Beschreibung</td></tr><tr><td><div>Dieses generische Template kann in den speziellen Leitfäden spezifiziert werden. Ob ein Problem codiert angegeben werden muss und welche Codesysteme zur Anwendung kommen müssen bzw. sollen, ergibt sich aus dem Kontext des jeweiligen speziellen Implementierungsleitfadens. <div> Das Problem Entry erlaubt die Dokumentation eines Gesundheitsproblems, das verschiedene Ausprägungen (im code-Element) haben kann :</div><div><ul><li>Diagnose (Diagnosis)</li><li>Problem (Problem)</li><li>Zustand (Condition)</li><li>Symptom (Symptom)</li><li>Befund (Finding)</li><li>Beschwerde (Complaint)</li><li>Funktionelle Einschränkung (Functional limitation)</li></ul></div><div>Um welches Problem es sich handelt, wird im value-Element angegeben. Da es sich bei einem Problem technisch um eine observation, also eine dokumentierte Beobachtung handelt, erhält sie den fixen StatusCode "completed". Der Status des Gesundheitsproblems selbst kann über das darin liegende Entry "Problem Status Observation" angegeben werden. </div><div> </div><div>Die effectiveTime ("medizinisch relevante Zeit") ist der Zeitraum, zu dem die Beobachtung für den Patienten gilt. Für z.B. einen Arzt, der heute einen Patienten in der Klinik behandelt und einen Herzinfarkt dokumentiert, der vor fünf Jahren aufgetreten ist, liegt die effectiveTime fünf Jahre zurück.</div><div><ul><li>effectiveTime.low („Beginn des Problems“): Entspricht dem Zeitpunkt, zu dem das Problem erstmals aufgetreten ist (z.B. der Start der Erkrankung oder Beginn der Symptome). Kann auch unbekannt sein (nullFlavor "UNK")</li><li>effectiveTime.high („Ende des Problems“): Gibt den Zeitpunkt an, seitdem die zugrunde liegende Erkrankung nicht mehr besteht ("Zustand nach" oder „status post“). Wenn es nicht angegeben ist, gilt das Problem als weiterhin bestehend. Wenn bekannt ist, dass das Problem nicht mehr auftritt, dann MUSS ein effectiveTime.high angegeben werden. Wenn das Datum der Lösung nicht bekannt ist, dann wird der nullFlavor "UNK" angegeben.</li></ul></div><div>Weitere Informationen:</div><div>Das Problem Entry erlaubt die Angabe weiterer Informationen zum Problem:</div><div><ul><li>value.qualifier: Typ der Diagnose (Haupt-, Nebendiagnose, Dauerdiagnose)</li><li>targetSiteCode / Laterality Qualifier: Seitenlokalisation und anatomische Lage (links, rechts)</li><li>entryRelationship.Problem Status Observation: Medizinischer Status des Gesundheitsproblems (bestehend, nicht mehr bestehend)</li><li>entryRelationship.Certainty Observation: Diagnosesicherheit (bestätigt, unbestätigt, Verdacht, ...)</li><li>entryRelationship.Severity Observation: Schweregrad der Erkrankung (schwer, mittel, leicht)</li><li>entryRelationship.Criticality Observation: Kritikalität des Gesundheitsproblems (lebensbedrohend, nicht lebensbedrohend, unbekannt) </li><li>entryRelationship.Comment Entry: Kommentar</li></ul></div><div> </div></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 1.2.40.0.34.6.0.11.3.6</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Entry 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 width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt 12 Templates</td></tr><tr><td><div><table width="100%" border="0" cellspacing="1" cellpadding="3" class="artdecor " 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;">1.2.40.0.34.6.0.11.9.1</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:~~Kyellow~~Kgreen.png|14px]] Narrative Text Reference (1.0.1+20210512)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.2</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Original Text Reference (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.42</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Laterality Qualifier (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.17</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Performer Body (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.36</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Author Body (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.3</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Informant Body (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.13</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Body (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.11</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Comment Entry (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.38</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Severity Observation (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.35</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Criticality Observation (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.36</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Certainty Observation (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.49</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Problem Status Observation (1.0.0+20210219)</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">Version: Template 1.2.40.0.34.6.0.11.3.6 Problem Entry (2019‑01‑18 09:59:00) <div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div> Adaptation: Template 1.3.6.1.4.1.19376.1.5.3.1.4.5 IHE Problem Entry (DYNAMIC) <div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">ch-pcc-</div> Spezialisierung: Template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07) <div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">ad1bbr-</div></td></tr><tr class="explabel " style="vertical-align: top;"><th class="" style="width: 20em; text-align: left;">Beispiel</th><td colspan="3" class="explabelgreen"><table width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable">Beispiel Diagnose codiert</td></tr><tr><td><hl7:observation classCode="OBS" moodCode="EVN" negationInd="false"> <hl7:templateId root="1.2.40.0.34.6.0.11.3.6"/> <hl7:templateId root="2.16.840.1.113883.10.20.1.28"/> <hl7:templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/> <hl7:id root="1.2.3.999" extension="--example only--"/> <hl7:code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>  <statusCode code="completed"/> <hl7:effectiveTime> <hl7:low value="20190817121500+0200"/> </hl7:effectiveTime> <hl7:value xsi:type="CD" code="cs" codeSystem="1.2.3.999">   <hl7:qualifier> <hl7:name code="106229004" codeSystem="2.16.840.1.113883.6.96"/> <hl7:value code="8319008" displayName="Principal diagnosis (contextual qualifier) (qualifier value)" codeSystem="2.16.840.1.113883.6.96"/> </hl7:qualifier> </hl7:value> <hl7:targetSiteCode> <hl7:qualifier> <hl7:name code="272741003" codeSystem="2.16.840.1.113883.6.96" displayName="Laterality"/> <hl7:value code="..." codeSystem="2.16.840.1.113883.6.96"/> </hl7:qualifier> <hl7:qualifier> <hl7:name code="106233006" codeSystem="2.16.840.1.113883.6.96" displayName="Topographical modifier"/> <hl7:value code="..." codeSystem="2.16.840.1.113883.6.96"/> </hl7:qualifier> </hl7:targetSiteCode> <hl7:author>  </hl7:author> <hl7:entryRelationship typeCode="COMP" contextConductionInd="true">  </hl7:entryRelationship></hl7:observation></td></tr></table></td></tr><tr class="explabel " style="vertical-align: top;"><th class="" style="width: 20em; text-align: left;">Beispiel</th><td colspan="3" class="explabelblue"><table width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;" class="togglertreetable">Beispiel Uncodierte Angabe des Gesundheitsproblems</td></tr><tr><td><hl7:observation classCode="OBS" moodCode="EVN" negationInd="false"> <hl7:templateId root="1.2.40.0.34.6.0.11.3.6"/> <hl7:templateId root="2.16.840.1.113883.10.20.1.28"/> <hl7:templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/> <hl7:id root="1.2.3.999" extension="--example only--"/> <hl7:code code="282291009" codeSystem="2.16.840.1.113883.6.96" displayName="Diagnosis"/>  <statusCode code="completed"/> <hl7:effectiveTime> <hl7:low value="20190817121800+0200"/> </hl7:effectiveTime> <hl7:value xsi:type="CD" nullFlavor="NA">  <originalText> <reference value="#MyRef1"/> </originalText> </hl7:value> <hl7:author>  </hl7:author> <hl7:entryRelationship typeCode="COMP" contextConductionInd="true">  </hl7:entryRelationship></hl7:observation></td></tr></table></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" class="artdecor treetable" 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 cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td>hl7:observation </td></tr></table></td><td></td><td></td><td></td><td>Container zur Angabe eines Problems (Diagnose etc). </td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@classCode </td></tr></table></td><td>cs</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">OBS</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@moodCode </td></tr></table></td><td>cs</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">EVN</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@negationInd </td></tr></table></td><td>bl</td><td>1 … 1</td><td>R</td><td style="vertical-align: top;" colspan="2"><div>SOLL standardmäßig auf false gesetzt werden.</div><div>Kann auf true gesetzt werden, um anzuzeigen, dass das dokumentierte Problem nicht beobachtet wurde.</div></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:templateId </td></tr></table></td><td>II</td><td>1 … 1</td><td>M</td><td>ELGA</td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@root </td></tr></table></td><td>uid</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.40.0.34.6.0.11.3.6</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:templateId </td></tr></table></td><td>II</td><td>1 … 1</td><td>M</td><td>HL7 CCD Problem observation</td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@root </td></tr></table></td><td>uid</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">2.16.840.1.113883.10.20.1.28</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:templateId </td></tr></table></td><td>II</td><td>1 … 1</td><td>M</td><td>IHE Problem Entry</td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@root </td></tr></table></td><td>uid</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">1.3.6.1.4.1.19376.1.5.3.1.4.5</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:id </td></tr></table></td><td>II</td><td>1 … *</td><td>M</td><td><div>ID des Problem-Entry. </div><div>Auch wenn nur ein Problem-Entry angegeben ist, soll sich die ID von der ID des Problem/Bedenken-Entry unterscheiden.</div><div>Grundsätzlich sind die Vorgaben für „Identifikations-Elemente“ zu befolgen.</div></td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:code </td></tr></table></td><td>CD</td><td>1 … 1</td><td>M</td><td>Code des Problems. Die Art des angegebenen Problems (Diagnose, Symptom, etc.) wird codiert in diesem Element angegeben. <div>Verweis auf speziellen Implementierungsleitfaden:</div><div>Welche der Problemarten angegeben werden müssen bzw. sollen, kann im jeweiligen speziellen Implementierungsleitfaden eingeschränkt werden.</div></td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.10.35 atcdabbr_Problemarten_VS (DYNAMIC)</td></tr></table></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td>1 … 1</td><td>M</td><td colspan="2"> von 1.2.40.0.34.6.0.11.9.1 Narrative Text Reference (DYNAMIC)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:text </td></tr></table></td><td>ED</td><td>1 … 1</td><td>M</td><td></td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:reference </td></tr></table></td><td>TEL</td><td>1 … 1</td><td>M</td><td>Die Referenz auf den entsprechenden Text im menschenlesbaren Teil muss durch Bezugnahme auf den Inhalt[@ID] angegeben werden: reference[@value='#xxx']. Die Referenz ist mit einem ID-Attribut anzugeben, dieses Element DARF NUR den Textinhalt des codierten Inhalts mit Zusatzinformationen umschließen.

Alternativ kann @value auch mit dem url-scheme "http" oder "https" beginnen.

</td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><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>@value </td></tr></table></td><td></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 rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2"> error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">starts-with(@value,'#') or starts-with(@value,'http')</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2">The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content'-element, or begin with the 'http' or 'https' url-scheme.</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:statusCode </td></tr></table></td><td>CS</td><td>1 … 1</td><td>M</td><td>Muss unabhängig von effectiveTime auf „completed“ gesetzt werden. Der medizinische Status des Problems wird im entryRelationship.Problem Status Observation angegeben. </td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@code </td></tr></table></td><td rowspan="1" class="conf">CONF</td><td>1 … 1</td><td>F</td><td colspan="2">completed</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:effectiveTime </td></tr></table></td><td>IVL_TS</td><td>1 … 1</td><td>M</td><td><div>Zeitintervall, in dem das Problem existent war/ist.</div><div>Grundsätzlich sind die Vorgaben für „Zeit-Elemente“ zu befolgen.</div></td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:low </td></tr></table></td><td>TS.AT.VAR</td><td>1 … 1</td><td>M</td><td>„Beginn des Problems“: Entspricht dem Zeitpunkt, zu dem das Problem erstmals aufgetreten ist. Kann auch unbekannt sein (nullFlavor "UNK") </td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:high </td></tr></table></td><td>TS.AT.VAR</td><td>0 … 1</td><td>C</td><td><div>„Ende des Problems“: muss angegeben werden, wenn das Problem nicht mehr besteht.</div><div>Wenn nicht angegeben, gilt das Problem als weiterhin bestehend. </div><div>Ist kein Datum der Lösung bekannt, wird der nullFlavor "UNK" angegeben.</div></td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td>1 … 1</td><td></td><td colspan="2"><div><div>Gesundheitsprobleme dürfen nur wie folgt angegeben werden:</div><div><ul><li>Codierte Angabe des Gesundheitsproblems: @value enthält den Code des Gesundheitsproblems einem Value Set (ICD-10, ICPC2 ...). Die Attribute code, codeSystem, codeSystem, codeSystemName und displayName müssen vorhanden sein!</li><li>Codierte Angabe ohne passenden Code: xsi:type='CD', nullFlavor: OTH In diesem Fall ist das Element <translation> verpflichtend. originalText.reference enthält den Verweis auf die narrative Beschreibung des Problems!</li><li>Uncodierte Angabe: xsi:type='CD', nullFlavor: NA In diesem Fall ist die Textreferenz <originalText> verpflichtend. originalText.reference enthält den Verweis auf die narrative Beschreibung des Problems!</li></ul></div><div style="mso-element:para-border-div;border:solid windowtext 1.0pt; mso-border-alt:solid windowtext .5pt;padding:1.0pt 2.0pt 1.0pt 2.0pt; background:yellow;margin-left:8.75pt;margin-right:14.15pt">Hinweis: Die Wahl des Codesystems ist abhängig von der Problemart! Für Diagnosen kann ein gültiger Code aus der vom für Gesundheit zuständigen Bundesministeriums veröffentlichen aktuellen ICD-10 Liste herangezogen werden.</div></div>Elemente in der Auswahl:<ul><li>hl7:value[not(@nullFlavor)]</li><li>hl7:value[@nullFlavor='OTH']</li><li>hl7:value[@nullFlavor='NA']</li></ul></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:value </td></tr></table></td><td>CD</td><td>0 … 1</td><td></td><td>Codierte Angabe des Gesundheitsproblems </td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [not(@nullFlavor)]</td><td></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><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>@xsi:type </td></tr></table></td><td></td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">CD</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><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>@code </td></tr></table></td><td>cs</td><td>1 … 1</td><td>R</td><td style="vertical-align: top;" colspan="2"></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><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>@codeSystem </td></tr></table></td><td>oid</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 width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.10.201 ELGA_Problems (DYNAMIC)</td></tr></table></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td>1 … 1</td><td>M</td><td colspan="2"> von 1.2.40.0.34.6.0.11.9.2 Original Text Reference (DYNAMIC) <div>Eingegebener Freitext, der die Grundlage der im Entry angegebenen Information ist. Das Element verweist auf die Stelle im Textbereich (section.text), in dem das Problem beschrieben ist (ohne zusätzliche Informationen, wie Datum, Beschreibung, etc).</div><div>Grundsätzlich sind die Vorgaben für „Codierungs-Elemente“ zu befolgen.</div></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><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>hl7:originalText </td></tr></table></td><td>ED</td><td>1 … 1</td><td>M</td><td>Textinhalt, der codiert wurde. </td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><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>hl7:reference </td></tr></table></td><td>TEL</td><td>1 … 1</td><td>M</td><td>Die Referenz auf den entsprechenden Text im narrativen Teil muss durch Bezugnahme auf den Inhalt[@ID] angegeben werden: reference[@value='#xxx']. Die Referenz ist mit einem content-Element mit ID-Attribut anzugeben, dieses Element DARF NUR den Textinhalt des codierten Inhalts umschließen und KEINE zusätzlichen Markup oder Strukturelemente.</td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@value </td></tr></table></td><td></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 rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2"> error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">starts-with(@value,'#')</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2">The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content'-element.</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><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>hl7:qualifier </td></tr></table></td><td>CR</td><td>0 … *</td><td>R</td><td><div>Qualifier zur genaueren Beschreibung des Problems. </div><div>z.B. zur Angabe der Art der Diagnose.</div></td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [hl7:name [@code='106229004']]</td><td></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><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>hl7:name </td></tr></table></td><td>CD</td><td>1 … 1</td><td>M</td><td></td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@code </td></tr></table></td><td rowspan="2" class="conf">CONF</td><td>1 … 1</td><td>F</td><td colspan="2">106229004</td></tr><tr style="vertical-align: top;"><td><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@codeSystem </td></tr></table></td><td>1 … 1</td><td>F</td><td colspan="2">2.16.840.1.113883.6.96 (Snomed-CT)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><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>hl7:value </td></tr></table></td><td>CD</td><td>1 … 1</td><td>M</td><td></td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td class="conf">CONF</td><td colspan="4"><table width="100%" border="0" cellspacing="2" cellpadding="2" class="artdecor " style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.6.0.10.23 elgagab_Art_der_Diagnose_VS (DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><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>hl7:translation </td></tr></table></td><td>CD</td><td>0 … *</td><td></td><td><div>Dieses Feld wird verwendet, wenn Codes aus einem abweichenden Value Set angegeben werden. </div><div>z.B. für Übersetzungen in alternative Codesysteme oder wenn kein geeigneter Code im vorgegebene VS vorhanden ist.</div></td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:value </td></tr></table></td><td>CD</td><td>0 … 1</td><td></td><td>Codierte Angabe des Gesundheitsproblems ohne passenden Code </td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [@nullFlavor='OTH']</td><td></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><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>@xsi:type </td></tr></table></td><td></td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">CD</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><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>@nullFlavor </td></tr></table></td><td>cs</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">OTH</td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td>1 … 1</td><td>M</td><td colspan="2"> von 1.2.40.0.34.6.0.11.9.2 Original Text Reference (DYNAMIC) <div>Eingegebener Freitext, der die Grundlage der im Entry angegebenen Information ist. Das Element verweist auf die Stelle im Textbereich (section.text), in dem das Problem beschrieben ist (ohne zusätzliche Informationen, wie Datum, Beschreibung, etc).</div><div>Grundsätzlich sind die Vorgaben für „Codierungs-Elemente“ zu befolgen.</div></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><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>hl7:originalText </td></tr></table></td><td>ED</td><td>1 … 1</td><td>M</td><td>Textinhalt, der codiert wurde. </td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><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>hl7:reference </td></tr></table></td><td>TEL</td><td>1 … 1</td><td>M</td><td>Die Referenz auf den entsprechenden Text im narrativen Teil muss durch Bezugnahme auf den Inhalt[@ID] angegeben werden: reference[@value='#xxx']. Die Referenz ist mit einem content-Element mit ID-Attribut anzugeben, dieses Element DARF NUR den Textinhalt des codierten Inhalts umschließen und KEINE zusätzlichen Markup oder Strukturelemente.</td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@value </td></tr></table></td><td></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 rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2"> error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">starts-with(@value,'#')</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2">The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content'-element.</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><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>hl7:translation </td></tr></table></td><td>CD</td><td>1 … *</td><td>M</td><td><div style="margin: 0px 0px 4px; vertical-align: top;">Dieses Feld wird verwendet, wenn Codes aus einem abweichenden Value Set angegeben werden. </div><div style="margin: 0px 0px 4px; vertical-align: top;">z.B. für Übersetzungen in alternative Codesysteme oder wenn kein geeigneter Code im vorgegebene VS vorhanden ist.</div></td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:value </td></tr></table></td><td>CD</td><td>0 … 1</td><td></td><td>Uncodierte Angabe des Gesundheitsproblems </td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo [@nullFlavor='NA']</td><td></td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><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>@xsi:type </td></tr></table></td><td></td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">CD</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><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>@nullFlavor </td></tr></table></td><td>cs</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">NA</td></tr><tr class="explabel " style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td>Beispiel</td><td colspan="4" class="explabelblue"><div>Nicht-codierte Diagnosen</div><value xsi:type="CD" nullFlavor="NA"> <originalText> <reference value="#diag4_diagNotCoded"/> </originalText></value></td></tr><tr class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td>1 … 1</td><td>M</td><td colspan="2"> von 1.2.40.0.34.6.0.11.9.2 Original Text Reference (DYNAMIC) <div>Eingegebener Freitext, der die Grundlage der im Entry angegebenen Information ist. Das Element verweist auf die Stelle im Textbereich (section.text), in dem das Problem beschrieben ist (ohne zusätzliche Informationen, wie Datum, Beschreibung, etc).</div><div>Grundsätzlich sind die Vorgaben für „Codierungs-Elemente“ zu befolgen.</div></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><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>hl7:originalText </td></tr></table></td><td>ED</td><td>1 … 1</td><td>M</td><td>Textinhalt, der codiert wurde. </td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><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>hl7:reference </td></tr></table></td><td>TEL</td><td>1 … 1</td><td>M</td><td>Die Referenz auf den entsprechenden Text im narrativen Teil muss durch Bezugnahme auf den Inhalt[@ID] angegeben werden: reference[@value='#xxx']. Die Referenz ist mit einem content-Element mit ID-Attribut anzugeben, dieses Element DARF NUR den Textinhalt des codierten Inhalts umschließen und KEINE zusätzlichen Markup oder Strukturelemente.</td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@value </td></tr></table></td><td></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 rowspan="3" class="stron">Schematron assert</td><td style="background-color: #FFEEEE;">role</td><td colspan="2"> error</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">test</td><td colspan="2">starts-with(@value,'#')</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top;"><td style="background-color: white;" colspan="1"> </td><td style="background-color: #FFEEEE;">Meldung</td><td colspan="2">The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content'-element.</td><td style="background-color: white;"> </td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:targetSiteCode </td></tr></table></td><td>CD</td><td>0 … *</td><td>R</td><td>Anatomische Lage des Problems Beinhaltet 1.2.40.0.34.6.0.11.9.42 Laterality Qualifier (DYNAMIC)</td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:performer </td></tr></table></td><td></td><td>0 … *</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.9.17 Performer Body (DYNAMIC)</td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:author </td></tr></table></td><td></td><td>0 … *</td><td>R</td><td>Dieses Author-Element KANN verwendet werden, um anzugeben, wer das Problem dokumentiert hat. Wenn nicht angegeben, gilt das jeweils "darüberlegende" Author-Element (Section, Document) Beinhaltet 1.2.40.0.34.6.0.11.9.36 Author Body (DYNAMIC)</td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:informant </td></tr></table></td><td></td><td>0 … *</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.9.3 Informant Body (DYNAMIC)</td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:participant </td></tr></table></td><td></td><td>0 … *</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.9.13 Participant Body (DYNAMIC)</td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:entryRelationship </td></tr></table></td><td></td><td>0 … *</td><td>R</td><td>Beinhaltet 1.2.40.0.34.6.0.11.3.11 Comment Entry (DYNAMIC)</td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@typeCode </td></tr></table></td><td>cs</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">COMP</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@contextConductionInd </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">true</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:entryRelationship </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Dieses EntryRelationship dient zur Darstellung des Schweregrads des Gesundheitsproblems Beinhaltet 1.2.40.0.34.6.0.11.3.38 Severity Observation (DYNAMIC)</td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@typeCode </td></tr></table></td><td>cs</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">SUBJ</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@contextConductionInd </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">true</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:entryRelationship </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Dieses EntryRelationship dient zur Darstellung der Kritikalität des Gesundheitsproblems. Beinhaltet 1.2.40.0.34.6.0.11.3.35 Criticality Observation (DYNAMIC)</td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@typeCode </td></tr></table></td><td>cs</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">SUBJ</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@inversionInd </td></tr></table></td><td>bl</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">true</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@contextConductionInd </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">true</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:entryRelationship </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Dieses EntryRelationship dient zur Darstellung der Gewissheit, mit der das Gesundheitsproblem Beinhaltet 1.2.40.0.34.6.0.11.3.36 Certainty Observation (DYNAMIC)</td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@typeCode </td></tr></table></td><td>cs</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">SUBJ</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@contextConductionInd </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">true</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table cellpadding="1" class="artdecor ad-diffblock-horizontal " style="background: transparent;border: none;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>hl7:entryRelationship </td></tr></table></td><td></td><td>0 … 1</td><td>R</td><td>Klinischer Status des Gesundheitsproblems Beinhaltet 1.2.40.0.34.6.0.11.3.49 Problem Status Observation (DYNAMIC)</td><td style="background-color: #FFEEEE;">(atc...lem)</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@typeCode </td></tr></table></td><td>cs</td><td>1 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">REFR</td></tr><tr style="vertical-align: top;"><td style="vertical-align: top;" class="columnName"><table cellpadding="1" class="artdecor " style="background: transparent;border: 0;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td>@contextConductionInd </td></tr></table></td><td>cs</td><td>0 … 1</td><td>F</td><td style="vertical-align: top;" colspan="2">true</td></tr></table></td></tr></table>

ADbot

Bots

144.664

Bearbeitungen

Änderungen

1.2.40.0.34.6.0.11.3.6/static-2020-11-06T100841

Navigationsmenü

Meine Werkzeuge

Namensräume

Varianten

Ansichten

Mehr

Suche

Navigation

Leitfäden

Wissensbasis

Hilfe

Werkzeuge