1.2.40.0.34.6.0.11.3.6/static-2019-01-18T095900: Unterschied zwischen den Versionen

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<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" 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 <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div></span></td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2019‑01‑18 09:59:00</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Entwurf</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;">2019</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;">Anzeigename</th><td style="text-align: left;">Problem Entry</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beschreibung</th><td style="text-align: left;" colspan="3">Problem als strukturiertes Entry (z.B. Syptom, Beschwerde, Diagnose etc.)<br />Dieses allgemeine Template ist das Eltern-Template und wird in dem jeweiligen Leitfäden spezialisiert.</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 1.2.40.0.34.6.0.11.3.6</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">Offen (auch andere als die definierten 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 class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt 4 Templates</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" 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.png|14px]] Narrative Text Reference (2019)</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:Kyellow.png|14px]] Original Text Reference (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.8</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Author Body (2019)</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:Kyellow.png|14px]] Comment Entry (2019)</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">Spezialisierung: Template 1.3.6.1.4.1.19376.1.5.3.1.4.5 <i>IHE Problem Entry </i> (DYNAMIC) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">IHE-PCC-</div></span><br />Spezialisierung: Template 2.16.840.1.113883.10.12.303 <i>CDA Observation </i> (2005‑09‑07) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">ad1bbr-</div></span></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" 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 class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:observation<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Container zur Angabe eines Problems (Diagnose etc).<br />
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<table xmlns="http://www.w3.org/1999/xhtml" class="artdecor" width="100%" border="0" cellspacing="3" cellpadding="2" 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 <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">at-cda-bbr-</div></span></td><th style="width: 20em; text-align: left;">Gültigkeit</th><td style="text-align: left;">2019‑01‑18 09:59:00</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Status</th><td style="text-align: left;">[[File:Kyellow.png|14px]] Entwurf</td><th style="width: 20em; text-align: left;">Versions-Label</th><td style="text-align: left;">2019</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;">Anzeigename</th><td style="text-align: left;">Problem Entry</td></tr><tr style="vertical-align: top;"><th style="width: 20em; text-align: left;">Beschreibung</th><td style="text-align: left;" colspan="3">Problem als strukturiertes Entry (z.B. Syptom, Beschwerde, Diagnose etc.)<br />Dieses allgemeine Template ist das Eltern-Template und wird in dem jeweiligen Leitfäden spezialisiert.</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 1.2.40.0.34.6.0.11.3.6</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">Offen (auch andere als die definierten 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 class="treetable" width="100%" border="0" cellspacing="3" cellpadding="2" style="background: transparent;"><tr class="desclabel"><td style="height: 1.5em;">Benutzt 4 Templates</td></tr><tr><td><div><table class="artdecor" width="100%" border="0" cellspacing="1" cellpadding="3" 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.png|14px]] Narrative Text Reference (2019)</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:Kyellow.png|14px]] Original Text Reference (2019)</td><td style="text-align: left;">DYNAMIC</td></tr><tr><td style="text-align: left;">1.2.40.0.34.6.0.11.9.8</td><td style="text-align: left;">Containment</td><td style="text-align: left;">[[File:Kyellow.png|14px]] Author Body - eImpfpass (2019)</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:Kyellow.png|14px]] Comment Entry (2019)</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">Spezialisierung: Template 1.3.6.1.4.1.19376.1.5.3.1.4.5 <i>IHE Problem Entry </i> (DYNAMIC) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">IHE-PCC-</div></span><br />Spezialisierung: Template 2.16.840.1.113883.10.12.303 <i>CDA Observation </i> (2005‑09‑07) <span xmlns="" class="repobox"><div class="repo ref sspacing">ref</div><div class="non-selectable repo refvalue sspacing">ad1bbr-</div></span></td></tr><tr style="vertical-align: top;"><td colspan="4" class="tabtab"><table class="treetable" id="transactionTable" width="100%" border="0" cellspacing="3" cellpadding="2" 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 class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td><tt><strong>hl7:observation<br /></strong></tt></td></tr></table></td><td><strong></strong></td><td><span style="color: black;"><strong></strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Container zur Angabe eines Problems (Diagnose etc).<br />
 
       </td><td style="background-color: #FFEEEE;"><span title="">(atc...lem)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></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">OBS</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@moodCode<br /></strong></tt></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><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@negationInd<br /></strong></tt></td></tr></table></td><td>bl</td><td><span><strong>1 … 1</strong></span></td><td>R</td><td style="vertical-align: top;" colspan="2"><div>SOLL standardmäßig auf false gesetzt werden.</div>
 
       </td><td style="background-color: #FFEEEE;"><span title="">(atc...lem)</span></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@classCode<br /></strong></tt></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">OBS</td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@moodCode<br /></strong></tt></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><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@negationInd<br /></strong></tt></td></tr></table></td><td>bl</td><td><span><strong>1 … 1</strong></span></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 <u>nicht</u> beobachtet wurde.</div>
 
           <div>Kann auf true gesetzt werden, um anzuzeigen, dass das dokumentierte Problem <u>nicht</u> beobachtet wurde.</div>
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             </div>Angabe der Seitenlokalisation als Kind-Element des value-Elements des Problems (Diagnose)</td><td style="background-color: #FFEEEE;"><span title="">(atc...lem)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo  <i> [hl7:name [@code='7']]</i></td></tr></table></td><td></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><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><tt><strong>hl7:name<br /></strong></tt></td></tr></table></td><td><strong>CD</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="">(atc...lem)</span></td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><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><tt><strong>@code<br /></strong></tt></td></tr></table></td><td rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">7</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><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><tt><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.3.7.1.0</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><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><tt><strong>hl7:value<br /></strong></tt></td></tr></table></td><td><strong>CD</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(atc...lem)</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 class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.10.176 <i>ELGA_Seitenlokalisation </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:qualifier<br /></strong></tt></td></tr></table></td><td><strong>CR</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>Angabe der Sicherheit des Problems ("Diagnosesicherheit")</td><td style="background-color: #FFEEEE;"><span title="">(atc...lem)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo  <i> [hl7:name [@code='8']]</i></td></tr></table></td><td></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><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><tt><strong>hl7:name<br /></strong></tt></td></tr></table></td><td><strong>CD</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="">(atc...lem)</span></td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><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><tt><strong>@code<br /></strong></tt></td></tr></table></td><td rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">8</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><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><tt><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.3.7.1.0</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><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><tt><strong>hl7:value<br /></strong></tt></td></tr></table></td><td><strong>CD</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="">(atc...lem)</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 class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.10.168 <i>ELGA_Diagnosesicherheit </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:translation<br /></strong></tt></td></tr></table></td><td><strong>CE</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Codierung(en) des Problems in alternativen Codesystemen.<br />
 
             </div>Angabe der Seitenlokalisation als Kind-Element des value-Elements des Problems (Diagnose)</td><td style="background-color: #FFEEEE;"><span title="">(atc...lem)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo  <i> [hl7:name [@code='7']]</i></td></tr></table></td><td></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><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><tt><strong>hl7:name<br /></strong></tt></td></tr></table></td><td><strong>CD</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="">(atc...lem)</span></td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><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><tt><strong>@code<br /></strong></tt></td></tr></table></td><td rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">7</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><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><tt><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.3.7.1.0</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><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><tt><strong>hl7:value<br /></strong></tt></td></tr></table></td><td><strong>CD</strong></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><span style="color: color: black;"><strong>R</strong></span></td><td></td><td style="background-color: #FFEEEE;"><span title="">(atc...lem)</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 class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.10.176 <i>ELGA_Seitenlokalisation </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:qualifier<br /></strong></tt></td></tr></table></td><td><strong>CR</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>Angabe der Sicherheit des Problems ("Diagnosesicherheit")</td><td style="background-color: #FFEEEE;"><span title="">(atc...lem)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo  <i> [hl7:name [@code='8']]</i></td></tr></table></td><td></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><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><tt><strong>hl7:name<br /></strong></tt></td></tr></table></td><td><strong>CD</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="">(atc...lem)</span></td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><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><tt><strong>@code<br /></strong></tt></td></tr></table></td><td rowspan="2" class="conf">CONF</td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">8</td></tr><tr style="vertical-align: top;"><td><table class="artdecor" cellpadding="1" style="background: transparent;"><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><tt><strong>@codeSystem<br /></strong></tt></td></tr></table></td><td><span style="color: black;"><strong>1 … 1</strong></span></td><td><strong>F</strong></td><td colspan="2">2.16.840.1.113883.3.7.1.0</td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><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><tt><strong>hl7:value<br /></strong></tt></td></tr></table></td><td><strong>CD</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="">(atc...lem)</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 class="artdecor" width="100%" border="0" cellspacing="2" cellpadding="2" style="background: transparent;"><tr style="vertical-align: top;"><td>Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.10.168 <i>ELGA_Diagnosesicherheit </i>(DYNAMIC)</td></tr></table></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:translation<br /></strong></tt></td></tr></table></td><td><strong>CE</strong></td><td><span style="color: black;"><strong>0 … *</strong></span></td><td><span style="color: color: black;"><strong></strong></span></td><td>Codierung(en) des Problems in alternativen Codesystemen.<br />
−
           </td><td style="background-color: #FFEEEE;"><span title="">(atc...lem)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:author<br /></strong></tt></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></strong></span></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)<br />Beinhaltet 1.2.40.0.34.6.0.11.9.8 <i>Author Body</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(atc...lem)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo  <i> [hl7:assignedAuthor]</i></td></tr></table></td><td></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entryRelationship<br /></strong></tt></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></strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.3.11 <i>Comment Entry</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(atc...lem)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo  <i> [hl7:act]</i></td></tr></table></td><td></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></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">COMP</td></tr></table></td></tr></table>
+
           </td><td style="background-color: #FFEEEE;"><span title="">(atc...lem)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:author<br /></strong></tt></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></strong></span></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)<br />Beinhaltet 1.2.40.0.34.6.0.11.9.8 <i>Author Body - eImpfpass</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(atc...lem)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo  <i> [hl7:assignedAuthor]</i></td></tr></table></td><td></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td class="columnName"><table class="ad-diffblock-horizontal " cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>hl7:entryRelationship<br /></strong></tt></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></strong></span></td><td>Beinhaltet 1.2.40.0.34.6.0.11.3.11 <i>Comment Entry</i> (DYNAMIC)</td><td style="background-color: #FFEEEE;"><span title="">(atc...lem)</span></td></tr><tr style="vertical-align: top; background-color: #FFEAEA;"><td colspan="5" style="background-color: #FFEAEA;"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td> wo  <i> [hl7:act]</i></td></tr></table></td><td></td></tr><tr><td style="vertical-align: top;" class="columnName"><table class="artdecor" cellpadding="1" style="background: transparent;"><tr><td style="vertical-align: top;">[[File:Treeblank.png|16px]]</td><td style="vertical-align: top;">[[File:Treetree.png|16px]]</td><td><tt><strong>@typeCode<br /></strong></tt></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">COMP</td></tr></table></td></tr></table>

Version vom 7. August 2019, 04:24 Uhr

Id1.2.40.0.34.6.0.11.3.6
ref
at-cda-bbr-
Gültigkeit2019‑01‑18 09:59:00
StatusKyellow.png EntwurfVersions-Label2019
Nameatcdabbr_entry_ProblemAnzeigenameProblem Entry
BeschreibungProblem als strukturiertes Entry (z.B. Syptom, Beschwerde, Diagnose etc.)
Dieses allgemeine Template ist das Eltern-Template und wird in dem jeweiligen Leitfäden spezialisiert.
KontextElternknoten des Template-Element mit Id 1.2.40.0.34.6.0.11.3.6
KlassifikationCDA Entry Level Template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Benutzt
Benutzt 4 Templates
Benutzt als NameVersion
1.2.40.0.34.6.0.11.9.1InklusionKyellow.png Narrative Text Reference (2019)DYNAMIC
1.2.40.0.34.6.0.11.9.2InklusionKyellow.png Original Text Reference (2019)DYNAMIC
1.2.40.0.34.6.0.11.9.8ContainmentKyellow.png Author Body - eImpfpass (2019)DYNAMIC
1.2.40.0.34.6.0.11.3.11ContainmentKyellow.png Comment Entry (2019)DYNAMIC
BeziehungSpezialisierung: Template 1.3.6.1.4.1.19376.1.5.3.1.4.5 IHE Problem Entry (DYNAMIC)
ref
IHE-PCC-

Spezialisierung: Template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
ItemDTKardKonfBeschreibungLabel
hl7:observation
Container zur Angabe eines Problems (Diagnose etc).
(atc...lem)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl1 … 1R
SOLL standardmäßig auf false gesetzt werden.
Kann auf true gesetzt werden, um anzuzeigen, dass das dokumentierte Problem nicht beobachtet wurde.
Treetree.pnghl7:templateId
II1 … 1ELGA(atc...lem)
Treeblank.pngTreetree.png@root
uid1 … 1F1.2.40.0.34.6.0.11.3.6
Treetree.pnghl7:templateId
II1 … 1HL7 CCD Problem observation(atc...lem)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.20.1.28
Treetree.pnghl7:templateId
II1 … 1IHE Problem Entry(atc...lem)
Treeblank.pngTreetree.png@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.5
Treetree.pnghl7:id
II1 … 1M
ID des Problem-Entry. 
Auch wenn nur ein Problem-Entry angegeben ist, soll sich die ID von der ID des Problem/Bedenken-Entry unterscheiden.
Grundsätzlich sind die Vorgaben für „Identifikations-Elemente“ zu befolgen.
(atc...lem)
Treetree.pnghl7:code
CE1 … 1MCode des Problems.
Die Art des angegebenen Problems (Diagnose, Symptom, etc.) wird codiert in diesem Element angegeben.
           Verweis auf speziellen Implementierungsleitfaden:
Welche der Problemarten angegeben werden müssen bzw. sollen, kann im jeweiligen speziellen Implementierungsleitfaden eingeschränkt werden.
(atc...lem)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.10.35 ELGA_Problemarten (DYNAMIC)
Eingefügt1 … 1M von 1.2.40.0.34.6.0.11.9.1 Narrative Text Reference (DYNAMIC)
Treetree.pnghl7:text
ED1 … 1M(atc...lem)
Treeblank.pngTreetree.pnghl7:reference
TEL1 … 1MDie Referenz auf den entsprechenden Text im menschenlesbaren Teil muss durch Bezugnahme auf den Inhalt[@ID] angegeben werden: reference[@value='#xxx'].(atc...lem)
Treeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
 Schematron assertroleKred.png error 
 teststarts-with(@value,'#') 
 MeldungThe @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding <content/> element. 
 Variable letNameidvalue 
 Valuesubstring-after(@value,'#') 
 Schematron assertroleKred.png error 
 testancestor::hl7:structuredBody//*[@ID=$idvalue] 
 MeldungNo narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>'). 
Treetree.pnghl7:statusCode
CS1 … 1MFester Wert "completed"
(atc...lem)
Treeblank.pngTreetree.png@code
CONF1 … 1Fcompleted
Treetree.pnghl7:effectiveTime
IVL_TS1 … 1M
Zeitintervall, in dem das Problem existent war/ist.
Grundsätzlich sind die Vorgaben für „Zeit-Elemente“ zu befolgen.
(atc...lem)
Treeblank.pngTreetree.pnghl7:low
TS.AT.TZ1 … 1MZeitpunkt des ersten Auftretens des Problems.(atc...lem)
Treeblank.pngTreetree.pnghl7:high
TS.AT.TZ0 … 1CZeitpunkt, zu dem der Problemstatus auf "aborted" oder "completed" gesetzt wird. In allen anderen Fällen bleibt der Wert leer.(atc...lem)
 Schematron assertroleKred.png error 
 testcount(hl7:statusCode[@code='active'])=0 or count(hl7:effectiveTime/hl7:high)=0 
 MeldungIst das Element statusCode auf „active“ gesetzt, muss das high-Element des Zeitintervalls weggelassen werden. 
Treetree.pnghl7:value
CD1 … 1MProblem (codiert oder uncodiert).
         
Dieser Wert kann entweder ein codierter Wert oder ein uncodierter Text sein. Der Typ ist immer xsi:type='CD'. Für codierte Werte müssen die Attribute code, codeSystem, codeSystem, codeSystemName und displayName vorhanden sein.

Hinweis: Die Wahl des Codesystems ist abhängig von der Problemart!

(atc...lem)
Treeblank.pngTreetree.png@displayName
st0 … 1 
Treeblank.pngTreetree.png@code
cs1 … 1R
Treeblank.pngTreetree.png@codeSystem
oid1 … 1R
Treeblank.pngTreetree.png@codeSystemName
st0 … 1 
Eingefügt1 … 1M von 1.2.40.0.34.6.0.11.9.2 Original Text Reference (DYNAMIC)
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).
Grundsätzlich sind die Vorgaben für „Codierungs-Elemente“ zu befolgen.
Treeblank.pngTreetree.pnghl7:originalText
ED1 … 1MTextinhalt, der codiert wurde.
(atc...lem)
Treeblank.pngTreeblank.pngTreetree.pnghl7:reference
TEL1 … 1MEN-US.png Die Referenz auf den entsprechenden Text im narrativen Teil muss durch Bezugnahme auf den Inhalt[@ID] angegeben werden: reference[@value='#xxx'].(atc...lem)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
 Schematron assertroleKred.png error 
 teststarts-with(@value,'#') 
 MeldungThe @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding <content/> element. 
 Variable letNameidvalue 
 Valuesubstring-after(@value,'#') 
 Schematron assertroleKred.png error 
 testancestor::hl7:structuredBody//*[@ID=$idvalue] 
 MeldungNo narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>'). 
 Schematron assertroleKred.png error 
 testparent::*/text()=ancestor::hl7:structuredBody//*[@ID=$idvalue]/text() 
 MeldungThe originalText content MUST be identical to the narrative text for this reference. 
Treeblank.pngTreetree.pnghl7:qualifier
CR0 … 1R
Qualifier zur genaueren Beschreibung des Problems. 
z.B. zur Angabe der Diagnosesicherheit.
Angabe der Seitenlokalisation als Kind-Element des value-Elements des Problems (Diagnose)		(atc...lem)
Treeblank.pngTreeblank.png wo [hl7:name [@code='7']]
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CD1 … 1M(atc...lem)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF1 … 1F7
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.3.7.1.0
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD1 … 1R(atc...lem)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.10.176 ELGA_Seitenlokalisation (DYNAMIC)
Treeblank.pngTreetree.pnghl7:qualifier
CR0 … 1RAngabe der Sicherheit des Problems ("Diagnosesicherheit")(atc...lem)
Treeblank.pngTreeblank.png wo [hl7:name [@code='8']]
Treeblank.pngTreeblank.pngTreetree.pnghl7:name
CD1 … 1M(atc...lem)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
CONF1 … 1F8
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.3.7.1.0
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
CD1 … 1M(atc...lem)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 1.2.40.0.34.10.168 ELGA_Diagnosesicherheit (DYNAMIC)
Treeblank.pngTreetree.pnghl7:translation
CE0 … *Codierung(en) des Problems in alternativen Codesystemen.
(atc...lem)
Treetree.pnghl7:author
0 … *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 1.2.40.0.34.6.0.11.9.8 Author Body - eImpfpass (DYNAMIC)		(atc...lem)
Treeblank.png wo [hl7:assignedAuthor]
Treetree.pnghl7:entryRelationship
0 … *Beinhaltet 1.2.40.0.34.6.0.11.3.11 Comment Entry (DYNAMIC)(atc...lem)
Treeblank.png wo [hl7:act]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
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