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elga-cdaps-2.06.2:Grundsätze und Regeln

2.763 Bytes hinzugefügt, 16:01, 24. Nov. 2017
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Grundsätze und Regeln
==Zugeordnete codierte Information (Übersetzung)==
Es kann vorkommen, dass bestimmte Informationen codiert in der Quelldokumentation vorliegen, aber in einer anderen Terminologie als vom Leitfaden zugelassen. Wenn die codierten Konzepte korrekt von der einen in die andere Terminologie zugeordnet werden können (also "übersetzt" oder "gemappt"), ist es erlaubt, auch die originalen Codes zusätzlich anzugeben.
aber die Codes sind nicht in den im Leitfaden zugelassenen Terminologien (Value Sets) verfügbar
 
Case 1: single local code mapped to primary code from the reference value set.
 
<pre class="orange">
<value xsi:type="CD" code="42338000" codeSystem="2.16.840.1.113883.6.96"
displayName="Salmonella gastroenteritis">
[
<originalText>
<reference value="#ref1"/>
</originalText>
]
<translation code="003.0" codeSystem="2.16.840.1.113883.6.103"
displayName="Gastroenterite da Salmonella"/>
</value>
</pre>
 
The square brackets [ ] are used to indicate that the originalText element may or may not be present
 
Case 2: multiple local codes mapped together using nested 'translation' elements, and mapped to the primary code from the reference value set
 
 
<pre class="orange">
<value xsi:type="CD" code="422479008" codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"
displayName="FEMALE BREAST INFILTRATING DUCTAL CARCINOMA, STAGE 2">
[
<originalText>
<reference value="#problem4name"/>
</originalText>
]
<translation code="code-example" codeSystem="1.999.999"
codeSystemName="this is only an example"
displayName="FEMALE BREAST INFILTRATING DUCTAL CARCINOMA, STAGE 2">
<translation code="174.9" codeSystem="2.16.840.1.113883.6.103"
codeSystemName="ICD-9CM"
displayName="Malignant neoplasm of breast (female), unspecified"/>
<translation code="C50.919" codeSystem="2.16.840.1.113883.6.90"
codeSystemName="ICD-10-CM"
displayName="Malignant neoplasm of unspecified site of unspecified female breast"/>
</translation>
</value>
</pre>
 
Case 3: original and the reference coded concepts belong to the same code system (distinct codes). This may be the result of a different level of granularity between the original term and the reference value sets.
<pre class="orange">
<code code="60591-5" codeSystem="12.216.40840.01.34113883.56.1741" nullFlavor codeSystemName="OTHLOINC" displayName="Patient Summary"> <originalText>translation code="60592-3" codeSystem="2.16.840.1.113883.6.1" <reference valuedisplayName="#ref1Patient summary unexpected contact"/> </originalText>
</code>
</pre>
Note: The R1 data type definition identifies the <translation> as “a set of other concept descriptors that translate this concept descriptor into other code systems. There is however a common understanding that “it may be more than one representation in a single code system where code systems allow multiple representations, such as SNOMED CT”. Data Types R2 extended the possibility to provide translations also in the same code system.
==Translation of designations ==
2.168
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