Änderungen

die Probenverfolgung in einem pathologischen Labor ab.</p><p></p></div></td></tr></table></td></tr><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 1.2.40.0.34.6.0.11.3.193</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Label</th><td style="text-align: left;" colspan="3">atpatho_entry_SpecimenProcedureStep<br /></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 4 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: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;">1.2.40.0.34.6.0.11.9.24</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Performer - Laboratory (1.0.0+20211213)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.70</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Participant Procedure Steps (1.0.0)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.3.162</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kgreen.png|14px]] Specimen Received (1.0.0+20211213)</td><td style="text-align: left;">DYNAMIC</td></tr></table></div></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="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"><span class="expcaption">Beispiel</span></td></tr><tr><td><span style="font-family: Courier, 'Courier New', monospace; "><span style="display: block;" class="explrendered"><span class="ppsign">&lt;</span><span class="ppelement">procedure</span> <span class="ppattribute">classCode</span><span class="ppsign">="</span><span class="ppcontent">PROC</span><span class="ppsign">"</span> <span class="ppattribute">moodCode</span><span class="ppsign">="</span><span class="ppcontent">EVN</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.40.0.34.6.0.11.3.193</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">templateId</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.3.6.1.4.1.19376.1.3.10.4.1</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">id</span> <span class="ppattribute">root</span><span class="ppsign">="</span><span class="ppcontent">1.2.3.999</span><span class="ppsign">"</span> <span class="ppattribute">extension</span><span class="ppsign">="</span><span class="ppcontent">--example only--</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">code</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- include template 1.2.40.0.34.6.0.11.9.1 'Narrative Text Reference' (dynamic) 1..1 M --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">statusCode</span> <span class="ppattribute">code</span><span class="ppsign">="</span><span class="ppcontent">completed</span><span class="ppsign">"</span><span class="ppsign">/</span><span class="ppsign">&gt;</span></span><span style="display: block;">  <span style="color:green">&lt;!-- choice: 1..1 <br /> element hl7:effectiveTime[not(@nullFlavor)]<br /> element hl7:effectiveTime[@nullFlavor='UNK']<br /> --&gt;<br /></span></span><span style="display: block;">  <span style="color:green">&lt;!-- choice: 1..1 <br /> element hl7:target&#8203;Site&#8203;Code[not(@nullFlavor)]<br /> element hl7:target&#8203;Site&#8203;Code[@nullFlavor='UNK']<br /> --&gt;<br /></span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">performer</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.2.40.0.34.6.0.11.9.24 'Performer - Laboratory' (2021-04-08T11:49:48) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">performer</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">participant</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.2.40.0.34.6.0.11.9.70 'Participant Procedure Steps' (2026-07-15T08:35:34) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">participant</span><span class="ppsign">&gt;</span></span><span style="display: block;" class="explrendered">  <span class="ppsign">&lt;</span><span class="ppelement">entryRelationship</span> <span class="ppattribute">typeCode</span><span class="ppsign">="</span><span class="ppcontent">COMP</span><span class="ppsign">"</span> <span class="ppattribute">contextConductionInd</span><span class="ppsign">="</span><span class="ppcontent">true</span><span class="ppsign">"</span><span class="ppsign">&gt;</span><br /><span style="display: block;">    <span style="color:green">&lt;!-- template 1.2.40.0.34.6.0.11.3.162 'Specimen Received' (2021-01-18T14:25:23) --&gt;<br /></span></span>  <span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">entryRelationship</span><span class="ppsign">&gt;</span></span><span class="ppsign">&lt;/</span><span class="ppnamespace"></span><span class="ppelement">procedure</span><span class="ppsign">&gt;</span></span></span></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:procedure<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">atpa...Step</span></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><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>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">PROC</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><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>1 … 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:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:templateId<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>II</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="">atpa...Step</span></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@root<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.2.40.0.34.6.0.11.3.193</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:templateId<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>II</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="">atpa...Step</span></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@root<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td>uid</td><td><span><strong>1 … 1</strong></span></td><td>F</td><td style="vertical-align: top;" colspan="2">1.3.6.1.4.1.19376.1.3.10.4.1</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:id<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>II</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td>Prozedur-ID, die aus dem LIS stammt. Kann die Ziel-ID (Referenz-ID) für die untergeordnete Prozedur sein.</td><td style="background-color: #FFEEEE;"><span title="">atpa...Step</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:code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CD</strong> (extensible)</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>M</strong></span></td><td><p>Codierung der Prozedur, die das untersuchte Material als Ergebnis hatte.</ptd><ptd style="background-color: #FFEEEE;">TODO Value-Set erstellen<span title="">atpa...Step</pspan></td></tr><tr style="vertical-align: top;"><td style="background-color: #FFEEEEwhite;" 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;"><span titletr style="vertical-align: top;">atpa<td>Der Wert von @code SOLLTE gewählt werden aus dem Value Set 1.2.40.0.34.6.0.10.Step133 <i>ELGA_SpecimenProcedure </i>(DYNAMIC)</td></tr></spantable></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 1.2.40.0.34.6.0.11.9.1 <i>Narrative Text Reference</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:text<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>ED</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="">atpa...Step</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:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:reference<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>TEL</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>Die Referenz auf den entsprechenden Text im menschenlesbaren Teil muss durch Bezugnahme auf den Inhalt[@ID] angegeben werden: reference[@value='#xxx'].<br />Die Referenz ist mit einem <i>ID</i>-Attribut anzugeben, dieses Element DARF NUR den Textinhalt des codierten Inhalts mit Zusatzinformationen umschließen.<br /><br />Alternativ kann @value auch mit dem url-scheme "http" oder "https" beginnen.<br /><br /><br /></td><td style="background-color: #FFEEEE;"><span title="">atpa...Step</span></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@value<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td></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;"><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"><span class="pptext">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.</span></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:statusCode<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>CS</strong> (erforderlich)</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="">atpa...Step</span></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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">@code<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td rowspan="1" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">completed</td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td></td><td colspan="2"><div>Abnahmedatum/-zeit bzw. Dauer des Bearbeitungsschritts.</div>Elemente in der Auswahl:<ul><li>hl7:effectiveTime[not(@nullFlavor)]</li><li>hl7:effectiveTime[@nullFlavor='UNK']</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><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:effectiveTime<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>IVL_TS</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="">atpa...Step</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [not(@nullFlavor)]</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:Treetree.png|16px]]</td><td><span xmlns="" style="font-family: Courier, 'Courier New', monospace; font-weight: bold;">hl7:effectiveTime<br xmlns="http://www.w3.org/1999/xhtml" /></span></td></tr></table></td><td><strong>IVL_TS</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="">atpa...Step</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"> wo <i> [@nullFlavor='UNK']</i></td><td></td></tr><tr class="choice"><td style="font-style: italic;" colspan="2">Auswahl</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td></td><td colspan="2"><div><p>Entnahmeort im Körper oder relative Abstammungsbeziehung bei der Probenverarbeitung.</p><p>TODO Value-Set auf Basis von SNOMED erstellen oder SNOMED vorgeben.</p>

<p>Wurde der Befund nur von <strong>einem</strong> Institut erstellt, <strong>MUSS</strong> dieses in "/ClinicalDocument/documentationOf[1]/serviceEvent/performer" dokumentiert werden.</p><p>Sind <strong>mehrere</strong> Labors an der Erstellung beteiligt, <strong>MUSS</strong> das Labor im "structuredBody" entweder auf <strong>"entry"</strong> -Ebene oder im Rahmen eines <strong>"organizer"</strong> -Elementes oder direkt bei der Analyse ( <strong>"observation"</strong> -Element) angegeben werden. Angaben in tieferen Ebenen (z.B. "observation"-Ebene) überschreiben solche auf höheren Ebenen (z.B. "organizer"-Ebene).</p><p>Für den Fall, dass Analysen von einem externen Labor durchgeführt wurden, <strong>MUSS</strong> assignedEntity/code mit @code="E", @codeSystem="2.16.840.1.113883.2.16.1.4.9", @codeSystemName="HL7.at.Laborkennzeichnung" und @displayName="EXTERN" angegeben werden.</p>

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