A concise narrative from the patient’s perspective about their present health state. This is a record of the things that a person feels it is important to communicate about their needs, strengths, values, concerns and preferences to others providing support and care.
Patients unable to communicate can be supported by a proxy author. The patient’s story, provided here, may be told by the patient or by a proxy.
Klassifikation
CDA Section level template
Offen/Geschlossen
Offen (auch andere als die definierten Elemente sind erlaubt)
Benutzt
Benutzt 3 Templates
Benutzt
als
Name
Version
2.16.840.1.113883.10.22.4.14
Inklusion
IPS Body Author (STU1)
DYNAMIC
2.16.840.1.113883.10.12.319
Containment
CDA Informant (Body)
DYNAMIC
2.16.840.1.113883.10.22.3.15
Containment
IPS Translation Section (2021)
DYNAMIC
Item
DT
Kard
Konf
Beschreibung
Label
hl7:section
1 … 1
M
@classCode
cs
0 … 1
F
DOCSECT
hl7:templateId
II
1 … 1
M
@root
uid
1 … 1
F
2.16.840.1.113883.10.22.16
hl7:id
II
0 … *
R
hl7:code
CE.IPS
1 … 1
M
@code
CONF
1 … 1
F
81338-6
@codeSystem
1 … 1
F
2.16.840.1.113883.6.1 (LOINC)
hl7:title
ST
1 … 1
M
Patient’s story
hl7:text
SD.TEXT
1 … 1
M
Eingefügt
0 … *
von 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
hl7:author
0 … *
hl7:templateId
II
1 … 1
M
@root
uid
1 … 1
F
2.16.840.1.113883.10.22.4.14
hl7:time
TS.IPS.TZ
1 … 1
R
hl7:assignedAuthor
1 … 1
M
hl7:id
II
1 … *
R
hl7:code
0 … 1
R
Auswahl
0 … 1
Elemente in der Auswahl:
hl7:assignedPerson
hl7:assignedAuthoringDevice
hl7:assignedPerson
0 … 1
C
@classCode
cs
0 … 1
F
PSN
@determinerCode
cs
0 … 1
F
INSTANCE
hl7:name
PN
1 … *
R
Name of the person (e.g. the Healthcare Professional) authoring this document