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<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;">1.2.40.0.34.6.0.11.0.5</td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2019‑05‑10 09:04:27<div>Andere Versionen mit dieser Id:<ul><li>[[File:Kblank.png|14px]] elgaambbef_document_ambulanzbefund vom 2021‑02‑08 13:01:55</li><li>[[File:Kblank.png|14px]] elgaambbef_document_ambulanzbefund vom 2020‑10‑09 11:29:46</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</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Name</th><td style="text-align: left;">elgaambbef_document_ambulanzbefund</td><th style="width: 20em; text-align: left;">Bezeichnung</th><td style="text-align: left;">Ambulanzbefund</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>Der Ambulanzbefund stellt das Berichtwesen an weitere versorgende GDAs und den Patienten/die Patientin einer ambulanten Versorgung dar. Diese Spezifikation stellt im Allgemeinen die gemeinsamen Richtlinien und Anforderungen an Ambulanzbefunde, unabhängig von der medizinischen Fachrichtung, dar. Fachrichtungsspezifische Inhalte sind möglich, jedoch könnte es noch einer genaueren und innerhalb der Fachrichtung harmonisierten Darstellung benötigen.</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">Pfadname /</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Klassifikation</th><td style="text-align: left;" colspan="3">CDA Document 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 53 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;">1.2.40.0.34.6.0.11.1.10</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document Realm (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.30</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document TypeId (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.1</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document Id (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.45</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document StatusCode (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.46</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document TerminologyDate (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.44</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:KyellowKgreen.png|14px]] Document PracticeSettingCode (1.1.0+20210303)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.11</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document Effective Time (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.12</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document Confidentiality Code (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.13</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document Language (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.15</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document Set Id and Version Number (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.3</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:KyellowKgreen.png|14px]] Record Target (1.2.0+20210303)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.2</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:KyellowKgreen.png|14px]] Author (1.0.1+20210303)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.22</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Data Enterer (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.4</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Custodian (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.24</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Information Recipient (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.5</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Legal Authenticator (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.6</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Authenticator (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.20</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Fachlicher Ansprechpartner (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.23</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Hausarzt (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.27</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Auskunftsberechtigte Person (Notfallkontakt) (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.25</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Angehoerige (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.26</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Versicherung (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.29</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Betreuungsorganisation (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.28</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Weitere Behandler (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.21</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Participant Ein-, Ueber-, Zuweisender Arzt (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.9</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] In Fulfillment Of (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.33</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Documentation Of Service Event - Outpatient Report (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.14</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Document Replacement - Related Document (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.1.7</td><td style="text-align: left;">Inklusion</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Component Of - Encompassing Encounter (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.69</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Brieftext (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.17</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Konsultations- oder Überweisungsgrund - unkodiert (1.0.0+20201119)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.47</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Konsultations- oder Überweisungsgrund - kodiert (1.1.0+20201123 )</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.9</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Aktuelle Medikation - unkodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.63</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Medikationsliste PS - kodiert (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.41</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Allergien und Intoleranzen - unkodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.59</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Allergien und Intoleranzen - kodiert (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.10</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Anamnese (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.11</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Status, Diagnostik und Befunde - unkodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.57</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Status, Diagnostik und Befunde - kodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.83</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Diagnose - unkodiert (1.0.1)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.96</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Diagnose - kodiert (1.1.1)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.12</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Verlauf (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.25</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Zusammenfassende Beurteilung (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.22</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Durchgeführte Maßnahmen - unkodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.13</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Durchgeführte Maßnahmen - kodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.56</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Empfohlene Medikation - unkodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.21</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Empfohlene Medikation - kodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.23</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Weitere empfohlene Maßnahmen - unkodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.58</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Weitere empfohlene Maßnahmen - kodiert (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.26</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Weitere Informationen (1.0.0+20201105)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.61</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Willenserklärungen und andere juridische Dokumente (1.1.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.70</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Abschließende Bemerkung (1.0.0+20210219)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.2.71</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Beilagen (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;"><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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:ClinicalDocument<br xmlns="http://www.w3.org/1999/xhtml" /></span></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></td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr><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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@classCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></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">DOCCLIN</td></tr><tr><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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@moodCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></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 class="include"><td style="font-style: italic;" colspan="2">Eingefügt</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;;"><strong>M</strong></span></td><td colspan="2"> von 1.2.40.0.34.6.0.11.1.10 <i>Document Realm</i> (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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:realmCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CS</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> Hoheitsbereich des Dokuments. <br />
<br />
<div>Fester Wert: @code = AT</div>
<b>↔ Hinweis zum XDS-Mapping:</b> Dieses Element wird ins XDS-Attribut XDSDocumentEntry.healthcareFacilityTypeCode gemappt.</div>
<div>Zu berücksichtigen sind jeweils die Attribute @code, @codeSystem und @displayName.</div></td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr><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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@displayName<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>st</td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2"></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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:service​Provider​Organization<br xmlns="http://www.w3.org/1999/xhtml" /></span></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><div>Organisation, in deren Verantwortungsbereich der Patientenkontakt stattfand.</div><br />Beinhaltet 1.2.40.0.34.6.0.11.9.9 <i>Organization Compilation with name</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></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></td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr><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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@typeCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></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">COMP</td></tr><tr><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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@context​Conduction​Ind<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>bl</td><td><span><strong>0 … 1</strong></span></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:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:structuredBody<br xmlns="http://www.w3.org/1999/xhtml" /></span></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></td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr><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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@classCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></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">DOCBODY</td></tr><tr><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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@moodCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></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 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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:confidentialityCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CE</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></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 2.16.840.1.113883.1.11.16926 <i>x_BasicConfidentialityKind </i>(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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:language​Code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CS</strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></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 2.16.840.1.113883.1.11.11526 <i>HumanLanguage </i>(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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.69 <i>Brieftext</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td></td><td colspan="2"><div>Sektion "Konsultations- oder Überweisungsgrund". Die Angabe dieser Sektion kann in unkodierter als auch in kodierter (mit entry) erfolgen.</div>Elemente in der Auswahl:<ul><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.17']] welches enthält Template 1.2.40.0.34.6.0.11.2.17 <i>Konsultations- oder Überweisungsgrund - unkodiert</i> (DYNAMIC)</li><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.47']] welches enthält Template 1.2.40.0.34.6.0.11.2.47 <i>Konsultations- oder Überweisungsgrund - kodiert</i> (DYNAMIC)</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: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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.17 <i>Konsultations- oder Überweisungsgrund - unkodiert</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.17']]</i></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.47 <i>Konsultations- oder Überweisungsgrund - kodiert</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.47']]</i></td><td></td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td></td><td colspan="2"><div>Die Angabe der bestehenden Medikation kann analog zur Patient Summary (kodiert) erfolgen. Hierbei ist aus jetziger Sicht noch zu beachten, dass templates der Patient Summary noch nicht in das neue ELGA Building Block Repository aufgenommen wurden. Daher wird sich die OID der kodierten Medikationsliste voraussichtlich noch ändern. <br />Die Angabe der Medikationsliste kann auch in unkodierter Form erfolgen.</div>Elemente in der Auswahl:<ul><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.9']] welches enthält Template 1.2.40.0.34.6.0.11.2.9 <i>Aktuelle Medikation - unkodiert</i> (DYNAMIC)</li><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.63']] welches enthält Template 1.2.40.0.34.6.0.11.2.63 <i>Medikationsliste PS - kodiert</i> (DYNAMIC)</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: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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.9 <i>Aktuelle Medikation - unkodiert</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.9']]</i></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.63 <i>Medikationsliste PS - kodiert</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.63']]</i></td><td></td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td></td><td colspan="2">Elemente in der Auswahl:<ul><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.41']] welches enthält Template 1.2.40.0.34.6.0.11.2.41 <i>Allergien und Intoleranzen - unkodiert</i> (DYNAMIC)</li><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.59']] welches enthält Template 1.2.40.0.34.6.0.11.2.59 <i>Allergien und Intoleranzen - kodiert</i> (DYNAMIC)</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: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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.41 <i>Allergien und Intoleranzen - unkodiert</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.41']]</i></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.59 <i>Allergien und Intoleranzen - kodiert</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.59']]</i></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:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Die Sektion "Anamnese" kann unterschiedliche Sub-Sektionen enthalten. Diese Sub-Sektionen können kodiert oder unkodiert vorliegen. <br />Sollten keine Sub-Sektionen verwendet werden, kann in dieser Sektion "Anamnese" nur unkodierter Inhalt verwendet werden, i.e. die Verwendung von entries ist NICHT erlaubt.<br /><br />Mögliche Sub-Sektionen umfassen:<br />- Frühere Erkrankungen und Maßnahmen<br />- Schwangerschaften<br />- Medizinische Geräte und Implantate<br />- Beeinträchtigungen<br />- Impfungen<br />- Lebensstil<br />- Willenserklärungen und andere juridische Dokumente<br /><br /><br />Beinhaltet 1.2.40.0.34.6.0.11.2.10 <i>Anamnese</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td></td><td colspan="2"><div>Diese Sektion beinhaltet Angaben zu durchgeführten Befundungen und diagnostischen Maßnahmen<br />Mögliche Sub-Sektionen sind:<br />- Körperliche Untersuchung (z.B.: IPPAF)<br />- Vitalparameter (z.B.: Körpermasse, Größe)<br />- Fachspezifische Diagnostik (WICHTIG: Diese Sektion ist durch den vorliegenden Implementierungsleitfaden nicht spezifiziert. Erst durch fachspezifische Implementierungsleitfäden kann diese Sektion auch in kodierter Form geführt werden.<br />- Ausstehende Befunde</div>Elemente in der Auswahl:<ul><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.11']] welches enthält Template 1.2.40.0.34.6.0.11.2.11 <i>Status, Diagnostik und Befunde - unkodiert</i> (DYNAMIC)</li><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.57']] welches enthält Template 1.2.40.0.34.6.0.11.2.57 <i>Status, Diagnostik und Befunde - kodiert</i> (DYNAMIC)</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: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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.11 <i>Status, Diagnostik und Befunde - unkodiert</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.11']]</i></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.57 <i>Status, Diagnostik und Befunde - kodiert</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.57']]</i></td><td></td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td></td><td colspan="2"><div>Diese Sektion beinhaltet Angaben zu erhobenen Diagnosen.</div>Elemente in der Auswahl:<ul><li>hl7:component welches enthält Template 1.2.40.0.34.6.0.11.2.83 <i>Diagnose - unkodiert</i> (DYNAMIC)</li><li>hl7:component welches enthält Template 1.2.40.0.34.6.0.11.2.96 <i>Diagnose - kodiert</i> (DYNAMIC)</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: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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.83 <i>Diagnose - unkodiert</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.96 <i>Diagnose - kodiert</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Die Sektion "Verlauf" beschreibt in narrativer Form den Krankheits- bzw. Problemverlauf.<br />Beinhaltet 1.2.40.0.34.6.0.11.2.12 <i>Verlauf</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.25 <i>Zusammenfassende Beurteilung</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td></td><td colspan="2"><div>Die Angaben in der Sektion "Durchgeführte Maßnahmen" können kodiert oder unkodiert erfolgen. Als mögliche Sub-Sektion kann "Pflegemaßnahmen" angeführt werden.<br /><br /></div>Elemente in der Auswahl:<ul><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.22']] welches enthält Template 1.2.40.0.34.6.0.11.2.22 <i>Durchgeführte Maßnahmen - unkodiert</i> (DYNAMIC)</li><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.13']] welches enthält Template 1.2.40.0.34.6.0.11.2.13 <i>Durchgeführte Maßnahmen - kodiert</i> (DYNAMIC)</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: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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.22 <i>Durchgeführte Maßnahmen - unkodiert</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.22']]</i></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.13 <i>Durchgeführte Maßnahmen - kodiert</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.13']]</i></td><td></td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td></td><td colspan="2"><div>Die Sektion "Empfohlene Medikation" führt die durch den ambulanten Besuch verordnete Medikation. <br />WICHTIG: sollte es durch den ambulanten Besuch zu Änderungen der bestehenden Medikation kommen MUSS sichergestellt werden, dass dies auch im section/text ersichtlich ist. Hierbei ist eine textuelle Hervorhebung empfohlenen.<br />Für den Fall, dass diese Sektion kodiert angeführt wird MUSS darauf geachtet werden, dass die effectiveTime-Elemente darstellen ab wann/bzw. seit wann eine medikamentöse Therapie verordnet wurde.</div>Elemente in der Auswahl:<ul><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.56']] welches enthält Template 1.2.40.0.34.6.0.11.2.56 <i>Empfohlene Medikation - unkodiert</i> (DYNAMIC)</li><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.21']] welches enthält Template 1.2.40.0.34.6.0.11.2.21 <i>Empfohlene Medikation - kodiert</i> (DYNAMIC)</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: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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.56 <i>Empfohlene Medikation - unkodiert</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.56']]</i></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.21 <i>Empfohlene Medikation - kodiert</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.21']]</i></td><td></td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td></td><td colspan="2"><div>Diese Sektion kann folgende Sub-Sektionen beinhalten:<br />- Termine, Kontrollen, Wiederbestellung<br />- Empfohlene Anordnungen Pflege<br />- Geplante Untersuchungen<br />- Konservative Therapie<br />- Chirurgische Therapie<br /><br />Sollte keine Sub-Sektion verwendet werden, können die Angaben in dieser Sektion nur unkodiert geführt werden.</div>Elemente in der Auswahl:<ul><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.23']] welches enthält Template 1.2.40.0.34.6.0.11.2.23 <i>Weitere empfohlene Maßnahmen - unkodiert</i> (DYNAMIC)</li><li>hl7:component[hl7:section/hl7:templateId[@root='1.2.40.0.34.6.0.11.2.58']] welches enthält Template 1.2.40.0.34.6.0.11.2.58 <i>Weitere empfohlene Maßnahmen - kodiert</i> (DYNAMIC)</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: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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.23 <i>Weitere empfohlene Maßnahmen - unkodiert</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.23']]</i></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.58 <i>Weitere empfohlene Maßnahmen - kodiert</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [hl7:section/hl7:templateId [@root='1.2.40.0.34.6.0.11.2.58']]</i></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:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.26 <i>Weitere Informationen</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.61 <i>Willenserklärungen und andere juridische Dokumente</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.2.70 <i>Abschließende Bemerkung</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:component<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>In dieser Sektion können Beilagen (in XML-embedded) angehängt werden.<br /><br />Beinhaltet 1.2.40.0.34.6.0.11.2.71 <i>Beilagen</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(elg...und)</span></td></tr></table></td></tr></table>
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